Recurring concern

Failure to reliably monitor vulnerable residents during fire emergencies and drills

First to latest report 2 Nov 2017 — 3 Sep 2024

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
6

What this concern includes

Includes dedicated fire-safety processes for monitoring or checking residents before, during or after fire drills, fire-alarm activations or comparable fire emergencies, including safeguards for residents with dementia or other vulnerabilities.

What is not included
  • Excludes general resident supervision, welfare checks or clinical monitoring where the monitoring is not specifically tied to a fire drill, fire alarm or fire emergency.
  • Excludes generic fire-risk assessment, evacuation, alarm, building-design or emergency-access deficiencies unless they directly concern monitoring or checking vulnerable residents during a fire-related event.
  • Excludes generic staffing, training, policy or documentation deficiencies unless they directly cause unreliable resident monitoring within the fire-emergency process.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. South Yorkshire (Eastern)

    AI-generated summary

    Margaret Aitchison · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Margaret Aitchison, a resident of Broom Lane Care home, accessed a fire door and fell down an unheated stairwell after a fire alarm activation, sustaining traumatic injuries and being found hypothermic; she died from her injuries. The report raised concerns about inadequate resident and fire-exit checks after alarm activations and whether updated procedures had been effectively communicated and implemented.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of formal systems for checking residents after fire alarm activations

    Wider context from the report

    “The evidence from a care worker who was at the home at the relevant time, and remains a care worker at the home, that there are still no formal systems for checking of residents after fire alarm activations, is at odds with the evidence I heard from the care manager that there had been comprehensive changes and a training programme implemented. I am concerned that the processes, protocols and expectations have not been effectively cascaded to those providing care to residents in homes. Accordingly, I invite you to consider the following and in particular whether there is a need for: 1. Further training of senior staff. 2. A requirement for senior staff to each put in place clear processes for staff to respond to fire alarm activations. 3. Training of carers, and any other relevant staff members, in terms of checking resident safety and fire door exits. ”

    Source location

    Margaret Aitchison · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Norfolk

    AI-generated summary

    John NICHOLS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    John Nichols died at Queen Elizabeth Hospital, King’s Lynn, on 18 June 2017 after sustaining a head injury when a fire door closed between him and his carer shortly after a fire drill at his care home. The concern was that the Fire Drills Policy did not provide sufficient safeguards to ensure residents, particularly those with dementia, were monitored before, during and after fire drills.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient safeguards for monitoring residents, particularly those with dementia, before, during, and after fire drills

    Wider context from the report

    “That the Fire Drills Policy currently in place does not include sufficient safeguards to ensure that residents (and in particular those with dementia) are sufficiently monitored before, during, and after fire drills. ”

    Source location

    John NICHOLS · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Engage a fire consultant to observe and comment on the Group’s fire-drill procedures.

    Verbatim wording from the response

    “1. Engaged the services of Steve Wiltshire AIFSM (“SW”), a Fire Consultant to observe and comment on the Group’s fire drill procedures. We enclose a copy of his report for your consideration (“The Report”).”

    Source location

    2017-0344-Response-by-Kings-Lynn-and-Eastgate-Residential-Care-Homes
    Page 2 · response
    Published 4 February 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review and amend the Group’s Fire Drill Procedure, Pre-Assessment Procedure and Personal Emergency Evacuation Plan to improve resident safety.

    Verbatim wording from the response

    “2. Internally reviewed and amended where necessary the Group’s Fire Drill Procedure, the Pre-Assessment Procedure and the Personal Emergency Evacuation Plan (“PEEP”) after carefully considering SW’s Report and reviewing the safety of the residents.”

    Source location

    2017-0344-Response-by-Kings-Lynn-and-Eastgate-Residential-Care-Homes
    Page 2 · response
    Published 4 February 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement the fire consultant’s recommendations.

    Verbatim wording from the response

    “• We discussed the mistakes observed during the fire drill set out in the Fire Evacuation Record – Bay Tree Court (see Appendix 2) with SW and they were considered minor. We will implement his recommendations.”

    Source location

    2017-0344-Response-by-Kings-Lynn-and-Eastgate-Residential-Care-Homes
    Page 2 · response
    Published 4 February 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct a further operational audit at Kings Lynn once the new procedures are embedded.

    Verbatim wording from the response

    “• We consider that the observation of the fire drill at Bay Tree Court, another of the Group’s homes of the same type as Kings Lynn Residential, was not a problem because the fire procedures are exactly the same across all the homes. When the new procedures are bedded in we will undertake an operational audit at Kings Lynn again.”

    Source location

    2017-0344-Response-by-Kings-Lynn-and-Eastgate-Residential-Care-Homes
    Page 2 · response
    Published 4 February 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Consult existing residents and their next of kin about assistance required during fire drills.

    Verbatim wording from the response

    “4. For those residents who have already been admitted into our homes we will, over the next few months, consult with next of kin and residents to see if they require assistance during a fire drill.”

    Source location

    2017-0344-Response-by-Kings-Lynn-and-Eastgate-Residential-Care-Homes
    Page 3 · response
    Published 4 February 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement the amended Fire Drill Procedure across all homes, provide site-specific training, and reinforce the changes in annual fire-awareness updates.

    Verbatim wording from the response

    “5. [The Fire Drill Procedures have been amended to make clear that the answering of Nurscall bell continues as normal.] Consequently, we have amended the Group’s Fire Drill Procedure to reflect the changes to the above. This will be implemented across all the homes with the relevant training at each site. The annual Fire Awareness update will also re-iterate the changes made. We enclose a copy of the revised Fire Drill Procedure for your consideration (see Appendix 6).”

    Source location

    2017-0344-Response-by-Kings-Lynn-and-Eastgate-Residential-Care-Homes
    Page 3 · response
    Published 4 February 2018

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026