Concerns raised 1
Failure of window restrictor standards to address deliberate attempts to defeat restrictors View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
British Standards Institution Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Department of Health and Social Care
Contact the Health and Safety Executive about reviewing the British Standard for window restrictors.
View source
British Standards Institution
Amend BS 6375-2 clause 5.3 to cover windows used in circumstances described by the Coroner’s report.
View source
British Standards Institution
Introduce a BS 6375-2 annex specifying the test method for restricted sliding sash windows.
View source
British Standards Institution
Require glazing to withstand the 850 N point load and meet specified impact-resistance grades.
View source
British Standards Institution
Amend BS 6510 clause 12.2 to refer to BS 6375-2 clause 5.3 rather than the existing fixed load and duration.
View source
British Standards Institution
Check whether the proposed BS 6375-2 amendment conflicts with existing European standards.
View source
British Standards Institution
Discuss with CEN/TC 33 WG1 whether EN 14609 needs amendment to address restricted sliding sash windows.
View source See 4 more actions
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AI-generated summary
Terrence Roy Hubert Taylor · 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
Terrence Roy Hubert Taylor, an 82-year-old short-term resident of a residential care home, overcame a window restrictor, climbed out of a first-floor window and fell during the early hours of 11 December 2020, sustaining injuries from which he died. The principal concern was that current British Standards for window restrictors address accidental falls but not deliberate attempts to defeat them, and that this limitation and subsequent guidance on stronger restrictors were not generally known or understood by residential care home operators, manufacturers or suppliers.
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 Failure of window restrictor standards to address deliberate attempts to defeat restrictors
Wider context from the report “1. The concern relates to the guidance provided to operators of residential care homes in respect of window restrictors and the standard they are required to meet. The current standards have been developed to prevent accidental falling from windows. They do not deal with deliberate attempts to defeat the restrictor , which may well be the situation encountered residential care homes, as in fact occurred in this case. This limitation is not known or understood by operators of residential care homes.
2. In December 2013 the Department of Health published Health Building Note 00-10 Part D: Windows and associated hardware. That guidance was not directed to residential care home provides. The Guidance was updated following an earlier Coroner’s report to prevent future deaths addressed to the Chief Medical Officer. That Guidance Note provides that
“... window restrictors tested to current British Standards may be inadequate in preventing a determined effort to force a window open beyond 100mm ...”.
It also noted that:
“... The relevant tests for restrictors cited in BS EN 14351-1 and BS EN 13126-5 have been developed to prevent accidental falling from windows ... None of the British and European Standards deal with deliberate attempts to defeat the restrictor using impact forces , which may be the situation encountered in hospitals and care homes”.
3. The evidence was that this Guidance was not generally known or understood by operators of residential care homes or manufactures or suppliers of window restrictors.
4. In 2019 the Health and Safety Executive published Research Report RR1150 Review of Window Restrictors use in Health and Social Care. The outcome of that research was that in order to protect vulnerable people in health and social care premises:
“... it is suggested that window restrictors (and their fixings) are capable of withstanding push forces of at least 850N ...”.
5. Thus the HSE’s research suggests that window restrictors in health and social care premises should be able to withstand forces very much greater than that of the British Standards .
6. The evidence was that this research was not generally known or understood by operators of residential care homes or manufactures or suppliers of window restrictors.
7. Operators of care homes are likely to consider they are taking reasonable steps to secure windows by fitting restrictors that meet the British Standards, whereas the 2013 Department of Health Guidance and the 2019 Health and Safety Executive research indicates that is not so.
8. Action is required to ensure operators of care homes are provided with reliable, up to date guidance and to ensure that the limitations of the British Standard are widely known and understood by operators of residential care homes.
9. Action is required to review the British Standard relating to window restrictors to consider whether some different standard or qualification to the existing standard is required in respect of residential care homes and/or deliberate acts to disable window restrictors.
” Source location Terrence Roy Hubert Taylor · Prevention of Future Deaths report
Open source report
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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 Contact the Health and Safety Executive about reviewing the British Standard for window restrictors.
Verbatim wording from the response “In response to your second request for action, reviewing the British Standard is not within the scope of my Department's responsibilities. However, my officials have contacted HSE on this matter and await their reply.” Source location Response from DHSC
Open published response
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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 Amend BS 6375-2 clause 5.3 to cover windows used in circumstances described by the Coroner’s report.
Verbatim wording from the response “Amendments to BS 6375-2” Source location Response from BSI
Open published response
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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 Introduce a BS 6375-2 annex specifying the test method for restricted sliding sash windows.
Verbatim wording from the response “As BS EN 14609 does not cover loads applied to restricted sliding sash windows we will need to introduce a new annex to BS 6375-2 describing the test method to be used for such windows.” Source location Response from BSI
Open published response
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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 Require glazing to withstand the 850 N point load and meet specified impact-resistance grades.
Verbatim wording from the response “If loads are to be applied to the casement or sash then it will be necessary to upgrade the glazing so it can withstand comparable loads. We therefore propose that the glazing should be able to support the 850 N point load (applied via the pad) but also be grade 1(B)1 or 1(C)1 when tested in accordance with BS EN 12600. This will reduce the risk of egress being achieved by breaking the glass.” Source location Response from BSI
Open published response
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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 Amend BS 6510 clause 12.2 to refer to BS 6375-2 clause 5.3 rather than the existing fixed load and duration.
Verbatim wording from the response “Steel-framed windows” Source location Response from BSI
Open published response
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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 Check whether the proposed BS 6375-2 amendment conflicts with existing European standards.
Verbatim wording from the response “The load bearing capacity of safety devices is an essential characteristic of windows (reference Table ZA.1) therefore, when such a device is fitted to a window the loadbearing capacity of the window, when tested in accordance with BS EN 14609, must be stated on the manufacturer’s declaration of performance in accordance with article 4 (2) of the assimilated EU Regulation 305/2011 (The Construction Products Regulation).” Source location Response from BSI
Open published response
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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 Discuss with CEN/TC 33 WG1 whether EN 14609 needs amendment to address restricted sliding sash windows.
Verbatim wording from the response “BS EN 14609, is referred to by BS EN 14351-1 as the test method to determine the load bearing capacity of safety devices, but it only covers casement windows not sash windows, clause 7 calls for the restrictors to be disengaged and figures A.1 to A.6 show the movement of the casement to be limited by a “block” stopping the movement of one corner. We will discuss the possible need to amend EN 14609” Source location Response from BSI
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reviewing the British Standard for window restrictors is outside the Department’s responsibilities.
Verbatim wording from the response “In response to your second request for action, reviewing the British Standard is not within the scope of my Department's responsibilities. However, my officials have contacted HSE on this matter and await their reply.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National requirements for window safety products are for the country where the products are used to establish.
Verbatim wording from the response “BS EN 14351-1, the European product standard for windows and external pedestrian doors, doesn’t, as appears in for example the HSE report RR1150, limit the load bearing capacity of a safety device to 350 N but instead sets 350 N as the minimum, or threshold, value for such devices. It would be for the EU member state, or country in which the product is used, to set the national requirements for such products.” Source location Response from BSI
Open published response
22 Apr 2024 Chenyang Li · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Lack of sufficient window restrictors in student accommodation View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Scape Operations Ltd
Fit window restrictors to every window at Scape Bloomsbury.
View source
Scape Operations Ltd
Inspect window restrictors every three months, immediately remedy defects, and log the work in the PPM system.
View source
Scape Operations Ltd
Visually inspect the building façade weekly for window defects, immediately remedy issues, and log the work.
View source
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AI-generated summary
Chenyang Li · 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
Chenyang Li, a 23-year-old third-year undergraduate student, entered a friend’s sixth-floor apartment on 30 September 2023 and climbed out of a window, falling onto concrete and dying shortly afterwards from multiple severe injuries. The report raised concern that the window did not appear to have any, or sufficient, restrictors to prevent over-opening, despite the relevant student-accommodation standard requiring such stops.
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 sufficient window restrictors in student accommodation
Wider context from the report “Students falling or jumping from windows is a known risk. Chenyang was able to easily jump to death from a 6th story window. Scope Bloomsbury is one of a number of is part of Scape Living Student Accommodation, a provider of purpose designed, student accommodation. The window Chenyang jumped from does not appear to have been fitted with any, or sufficient, form of window restrictors at all or as required under the National Code of Standards accreditation.
” Source location Chenyang Li · Prevention of Future Deaths report
Open source report
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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 Fit window restrictors to every window at Scape Bloomsbury.
Verbatim wording from the response “In line with the guidance set out by the National Code of Standards for Larger Developments for student accommodation not managed and controlled by educational establishments (the Code), each window at Scape Bloomsbury is fitted with a window restrictor; these were installed as part of the complete refurbishment of the building in 2018. The building will have received an inspection/sign-off from an inspector from The National Code at the time.” Source location Response from Scape Operations Ltd
Open published response
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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 Inspect window restrictors every three months, immediately remedy defects, and log the work in the PPM system.
Verbatim wording from the response “Over and above what is prescribed in the Code, the restrictors are periodically inspected every three months (as part of routine inspections of the condition of the student accommodation), with [on the rare occasion] any required remedial works undertaken immediately. This information is logged quarterly by the maintenance engineers within the building’s Planned Preventative Maintenance (PPM) system. In addition to three-monthly inspections of the window restrictors from within the bedroom, the building’s façade is also periodically visually inspected (weekly) to identify any remedial works required which would include windows appearing to be open beyond the tolerance allowable by the restrictor. Any issues are remediated immediately and logged by the maintenance team.” Source location Response from Scape Operations Ltd
Open published response
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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 Visually inspect the building façade weekly for window defects, immediately remedy issues, and log the work.
Verbatim wording from the response “Over and above what is prescribed in the Code, the restrictors are periodically inspected every three months (as part of routine inspections of the condition of the student accommodation), with [on the rare occasion] any required remedial works undertaken immediately. This information is logged quarterly by the maintenance engineers within the building’s Planned Preventative Maintenance (PPM) system. In addition to three-monthly inspections of the window restrictors from within the bedroom, the building’s façade is also periodically visually inspected (weekly) to identify any remedial works required which would include windows appearing to be open beyond the tolerance allowable by the restrictor. Any issues are remediated immediately and logged by the maintenance team.” Source location Response from Scape Operations Ltd
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing window restrictors, periodic inspections, immediate remedial works and maintenance logging are considered sufficient, so no further action is proposed.
Verbatim wording from the response “In line with the guidance set out by the National Code of Standards for Larger Developments for student accommodation not managed and controlled by educational establishments (the Code), each window at Scape Bloomsbury is fitted with a window restrictor; these were installed as part of the complete refurbishment of the building in 2018. The building will have received an inspection/sign-off from an inspector from The National Code at the time.” Source location Response from Scape Operations Ltd
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Scape UK Management is identified as the entity responsible for managing the building and the more appropriate recipient of the report.
Verbatim wording from the response “One minor point of clarification. The report is addressed to Scape Operations Ltd. The more appropriate entity to address would have been Scape UK Management, as this is the entity responsible for managing the building. Scape UK Management have been made aware of the report, and they are in agreement with this response.” Source location Response from Scape Operations Ltd
Open published response
17 Apr 2024 William Erskine · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2
Lack of a requirement to retrofit fixed window restrictors to existing windows View source Lack of Building Regulations requiring fixed window restrictors on opening windows in high-rise residential buildings View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Rt Hon Angela Rayner MP
Review the Decent Homes Standard, including whether to include specific measures on window restrictors.
View source
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AI-generated summary
William Erskine · 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
William Erskine died on 26 August 2023 after falling or jumping from the open window of his 16th-floor flat, sustaining multiple injuries. Concerns were raised that the windows could be fully opened because their restrictors could be released, and that current requirements do not require fixed window restrictors in high-rise residential buildings or their retrofitting to windows of this type.
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 a requirement to retrofit fixed window restrictors to existing windows
Wider context from the report “In the course of the evidence before the court, it was established that, whilst the windows in Mr Erskine’s flat were fitted with locks and dual-position window restrictors, the relevant restrictors can be released enabling the window to fully rotate within the frame (nominally to enable the resident to clean the glass). The degree to which the windows can be opened is therefore not restricted in the same way as if fixed window restrictors were fitted.
1. It is a matter of concern that, aside from certain buildings designed for educational or healthcare use, or provided for vulnerable adults, current Building Regulations do not require fixed window restrictors to be fitted to opening windows in high-rise residential buildings; and
2. In relation to windows of the type and design in use in Stretford House, there is no current requirement to retro-fit fixed window restrictors .
” Source location William Erskine · Prevention of Future Deaths report
Open source report × 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 Building Regulations requiring fixed window restrictors on opening windows in high-rise residential buildings
Wider context from the report “In the course of the evidence before the court, it was established that, whilst the windows in Mr Erskine’s flat were fitted with locks and dual-position window restrictors, the relevant restrictors can be released enabling the window to fully rotate within the frame (nominally to enable the resident to clean the glass). The degree to which the windows can be opened is therefore not restricted in the same way as if fixed window restrictors were fitted.
1. It is a matter of concern that, aside from certain buildings designed for educational or healthcare use, or provided for vulnerable adults, current Building Regulations do not require fixed window restrictors to be fitted to opening windows in high-rise residential buildings ; and
2. In relation to windows of the type and design in use in Stretford House, there is no current requirement to retro-fit fixed window restrictors.
” Source location William Erskine · Prevention of Future Deaths report
Open source report
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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 the Decent Homes Standard, including whether to include specific measures on window restrictors.
Verbatim wording from the response “Social housing must also meet the Decent Homes Standard. This sets out that social homes must be free from dangerous category 1 hazards, free from disrepair, have modern facilities and provide a reasonable degree of thermal comfort. The Regulator of Social Housing regulates the Decent Homes Standard in the social rented sector through its consumer standards, including the Safety and Quality Standard. The Government is committed to applying a Decent Homes Standard to the private rented sector for the first time through the Renters’ Rights Bill and we are reviewing the Decent Homes Standard to make sure that it is fit for purpose in setting the minimum standards that all rented homes must meet. This will include consideration of whether specific measures on window restrictors should be included in the Decent Homes Standard.” Source location Response from Ministry of Housing
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current housing standards and Building Regulations are considered proportionate and sufficient, so no additional regulatory measures are needed at this time.
Verbatim wording from the response “For tenants in existing buildings, risks of falls should be captured by existing housing standards, including the Housing Act 2004 and, for social housing tenants, the Decent Homes Standard, which I have described below. Changes introduced by the Social Housing (Regulation) Act 2023 (Awaab’s Law) will also place a duty on social landlords to address hazards in homes in set timeframes; the Government is committed to bringing forward secondary legislation to bring Awaab’s Law into force in the social rented sector. The Renters’ Rights Bill will also apply both the Decent Homes Standard and Awaab’s Law to the private rented sector for the first time, which will mean that tenants in this type of accommodation will benefit from similar protection and redress.” Source location Response from Ministry of Housing
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Building Act and Building Regulations powers are not retrospective and cannot require existing buildings to be modified or their layouts changed.
Verbatim wording from the response “Powers in the Building Act and the Building Regulations are not retrospective however and cannot require an existing building to be modified or change its layout.” Source location Response from Ministry of Housing
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Permanent window restrictors may conflict with ventilation, overheating mitigation, structural resistance and fire-escape requirements.
Verbatim wording from the response “Permanent window restrictors installed in dwellings to mitigate risk from falling from height could conflict with other requirements in Building Regulations, which may include providing adequate ventilation, mitigating overheating, resistance to lateral forces and, in two storey buildings, means of escape in the event of a fire. If mitigation of a risk from falling were reliant on guarding only, a permanent obstructing barrier such as a wall, suitably designed balustrade or glazing might be the most appropriate method of meeting Building Regulations.” Source location Response from Ministry of Housing
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Building Safety Regulator is responsible for reviewing protection-from-falling provisions and relationships between Building Regulations and their application limits.
Verbatim wording from the response “In 2022, a more stringent building safety regime was introduced overseen by the new Building Safety Regulator (BSR). The BSR has a statutory responsibility under the Building Safety Act 2022 to keep the safety of people in or about buildings, and the standard of buildings, under review and to make recommendations for improving standards to drive continuous improvement in the performance of all buildings to ensure the safety of occupants. Notwithstanding the processes already in place that I have set out above, it would be appropriate for the BSR, as part of its continuous review work, to consider how Building Regulations and Approved Documents ensure protection from falling; and to look at coherence and the relationships between different elements of the Building Regulations and the extent of limits of application.” Source location Response from Ministry of Housing
Open published response
Concerns raised 1
Lack of risk assessment of high-rise windows and their safety latches View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Sheffield City Council
Obtain an independent Chartered Surveyor’s review and report on high-rise windows and restrictors, including legal compliance and fixed-restrictor implications.
View source
Sheffield City Council
Undertake a risk assessment of high-rise windows after receiving the independent expert’s report.
View source
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AI-generated summary
Saffra Harriett Winn · 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
On 24 July 2022, Saffra Harriett Winn was found unconscious and not breathing on pavement between two high-rise blocks of flats after falling or jumping from a window of her flat. The report raised concerns that Sheffield City Council had not risk-assessed the windows or safety latches after two tenant fatalities, and lacked a formal process for investigating and assessing risks following catastrophic injuries or deaths in its social housing.
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 risk assessment of high-rise windows and their safety latches
Wider context from the report “The inquest heard that there have been two fatalities by tenants falling from this type of window in high-rise buildings in a short period of time between July 2022 and December 2023. Notwithstanding these fatal events, Sheffield City Council has not yet completed any risk assessment of the windows or the safety latches on the windows . A Building Safety Regulator was put in post at the council in January 2023, some 11 months before the second fatality and 6 months after the first, and this person has not been consulted in relation to the safety or risk posed by the windows. I am concerned that this poses a risk of future death.
More generally, I am concerned by Sheffield City Council’s in action in relation to the investigation and assessment of risk following cases of catastrophic injury and death within their social housing stock. I am concerned that a failure to properly investigate and risk assess any incident of this nature, together with the absence of any formal procedure or policy for this process, poses a risk of future death. There is no evidence before the inquest which alleviates my concern in this respect, in fact the inquest was told that the Head of Housing Investment and Maintenance for the council was not aware of the fatal incidents above until his attendance was required at this inquest.
” Source location Saffra Harriett Winn · Prevention of Future Deaths report
Open source report
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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 Obtain an independent Chartered Surveyor’s review and report on high-rise windows and restrictors, including legal compliance and fixed-restrictor implications.
Verbatim wording from the response “However, the Council has instructed an independent Chartered Surveyor to undertake a review and prepare a report of the windows in high-rise Council blocks. The expert has been asked to comment on issues including:” Source location Response from Sheffield City Council
Open published response
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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 Undertake a risk assessment of high-rise windows after receiving the independent expert’s report.
Verbatim wording from the response “The chartered building surveyor who has been instructed has expertise in structural and defect diagnosis, and safety, health and environment issues. The Council has asked the expert to advise on risk assessing the windows and the factors to be considered. The Council intends to undertake a risk assessment of the windows following receipt of the expert’s report. It is anticipated that this report will be received by SCC, no later than the 14th June 2024. The findings of this report and any subsequent recommendations will be shared with the Council’s Housing and Repairs Improvement Board which is Chaired by the Executive Director of Neighbourhood Services.” Source location Response from Sheffield City Council
Open published response
19 Jan 2020 Matthew WILLOUGHBY · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 1
Failure to ensure replacement of removed window safety adaptations View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Recipient name withheld
Replace the adapted windows in flat 10.
View source
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AI-generated summary
Matthew WILLOUGHBY · 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
Matthew WILLOUGHBY, aged 27, died on 9 August 2019 after inadvertently falling from a fourth-floor window while leaning out to shout to a passer-by. The principal concern was that window safety adaptations, previously advised by a council inspector to prevent someone climbing out, had been removed and not replaced, creating a risk to current and future tenants.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure replacement of removed window safety adaptations
Wider context from the report “• You have a number of tenants.
• I was not reassured that the adaptions removed from the window in the flat from which Matthew fell have since been replaced.
• Acknowledging that Matthew removed the adaptions himself, and that his reason for so doing was because he preferred to be able to open the window fully, as you advised in court an Inspector had advised that they be put in place and on grounds of safety.
• Regardless of whether you and / or your Husband advised Matthew that the adaptions were necessary, Matthew went on to reside in one of your flats for many months during which the window was able to open to the extent it could before the adaptions were added.
• There is a concern that if a Tenant of yours is intent on residing in conditions which are at odds with advice you have been given on grounds of the safety of your tenants and no action is taken by you as a Landlord beyond occasionally raising it with the Tenant, then this poses a risk to your current and future tenants.
” Source location Matthew WILLOUGHBY · Prevention of Future Deaths report
Open source report
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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 Replace the adapted windows in flat 10.
Verbatim wording from the response “Further to your letter in response to the above's recent demise,
in which you state we had a duty to notify you when we replaced the adaptation to flat 10 window.
I am informing you that we have replaced the stated adaptations to the windows in flat 10 and checked all the top floor flats windows were safe too.
We have enclosed photographic evidence of the same for your perusal.” Source location 2020-0016-Response-from-Landlord-Redacted
Open published response
12 Feb 2019 Bryan GRAY · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 1
Lack of window restrictors on other windows within the building View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Bryan GRAY · 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
Bryan Gray fell from a third-floor window at The Crossings in Kingston upon Hull on 21 July 2018, sustaining multiple injuries and dying later that day at Hull Royal Infirmary. It was unclear whether a window restrictor was in place or had been broken, and the investigation found that other windows in the building had no restrictors.
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 window restrictors on other windows within the building
Wider context from the report “(1) The deceased fell from a window. It was unclear whether a window restrictor was in place at the time of the incident or if it had been broken by him to enable him to climb over the window ledge
It is understood that this window restrictor has since been replaced with a wire cable type but it was established during the investigation that the other windows within the building did not have any window restrictors in place .
” Source location Bryan GRAY · Prevention of Future Deaths report
Open source report
11 May 2018 Marcus Anthony Allen · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Lack of restrictor devices on large lounge windows View source
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AI-generated summary
Marcus Anthony Allen · 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
Marcus Anthony Allen died on 1 June 2017 after falling from a window at his home, sustaining fatal head injuries. The principal concern was that the large lounge window had no restrictor device and could create a risk of falling when a person attempted to close it; other windows in the complex may have presented the same hazard.
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 restrictor devices on large lounge windows
Wider context from the report “(1) The large window in the lounge of flat ████████ has no restrictor device fitted . In consequence it can open to a position which necessitated a person leaning out of the window in order to close it. This was considered by witnesses to create a hazard involving a risk that a person may fall when attempting to close the window. It may be that other windows in the flat complex also have the same potential hazard.
” Source location Marcus Anthony Allen · Prevention of Future Deaths report
Open source report
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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 Follow up urgently with Estata on window surveys, restrictor repairs or replacements, and confirmation of completion and health-and-safety reporting.
Verbatim wording from the response “Having carefully considered your report, ████████ requested that an urgent survey of all windows at the development be carried out by Estata to check for restrictors and for them to be fitted wherever they were either not present or found to be faulty. As at the time of writing this letter, Estata have confirmed that it has completed its survey of all of the windows at the development and in a number of instances restrictors are missing or broken. ████████ asked Estata not to delay the remedial works pending completion of all surveys and that it should immediately install any missing restrictors and replace those found to be broken or faulty.” Source location 2018-0144-Response-by-Estates-Management-Limited
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintenance of windows and common parts is contractually assigned to Mill 39, with Estata responsible for carrying out those obligations.
Verbatim wording from the response “Our client, Radcliffe Investments, acquired the freehold interest in Whingate Mill on 1 August 2017, which comprises 39 residential apartments held by leaseholders on long leases and which was converted in around 2017. The leases are made between 3 contractual parties including the landlord, leaseholder and a management company, Mill 39 (Management) Limited (“Mill 39”). Pursuant to the terms of the long leases, Mill 39 is contractually responsible for the maintenance of the structure, exterior and common parts of the development, including the windows. We should point out that our client was not made aware of the tragic incident at the time of acquisition and was unaware until your letter notified us.” Source location 2018-0144-Response-by-Estates-Management-Limited
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5 Feb 2016 Samantha MacDonald · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2
Failure to keep bedroom window restrictors in good working order View source Failure of bedroom window restrictors to resist determined efforts to open windows View source
Linked responses
Campus Living Villages UK Limited Department for Business, Innovation & Skills
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Department for Business, Innovation & Skills
Write to UUK and GuildHE by early July, urging higher education institutions to improve student accommodation safety and addressing risk assessments and robust window restrictors.
View source
Campus Living Villages UK Limited
Enforce a signed student rule prohibiting interference with or removal of window restrictors.
View source
Campus Living Villages UK Limited
Inspect window restrictors each student term and before new intake, repairing damage and notifying students of sanctions where necessary.
View source
Campus Living Villages UK Limited
Conduct daily external checks for overcome window restrictors, taking action against students and reinstating restrictors when issues are identified.
View source
Campus Living Villages UK Limited
Display warnings and develop separate safety procedures when work requires removal of window restrictors.
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AI-generated summary
Samantha MacDonald · 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
On 25 October 2015, 20-year-old Samantha Jane MacDonald jumped from the window of her bedroom on the 14th floor of student accommodation in Salford and died. The window restrictor, which would have prevented the window opening sufficiently, was broken; similar devices in the building had also been found broken, raising concerns about the robustness and assessment of window restrictors in student accommodation.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to keep bedroom window restrictors in good working order
Wider context from the report “Samantha Macdonald jumped from the window of her bedroom on the 14th floor of her student accommodation in Salford. The window was not required to be used as a fire exit because it was too high. The window was fitted with a device that restricted the distance for which it would open. Evidence was heard that the device complied with the relevant British Standard and Planning regulations. If it had been in good working order it would have prevented the window from opening sufficiently to allow Samantha’s exit. It was, however, broken. Evidence revealed that the device could be broken by the application of force without the use of any tool. It was not possible to discover exactly when the device had been broken although it had been working during Samantha’s tenancy. Similar devices fitted to other bedrooms in the building had been found to be broken from time to time. The building is a non-smoking building that is entirely devoted to student accommodation, and witnesses believed that the devices had probably been broken so that students smoking in their rooms could avoid detection. Evidence was heard that in accommodation occupied by adults who might be determined to forcibly defeat window restrictors, for example in a healthcare setting, risk assessments were recommended to be reviewed and consideration given to replacing restrictors with more substantial or robust devices, and /or adding a second restrictor to better resist determined efforts to open the window, thus lessening the risk of persons falling either accidentally or otherwise. It is considered that such assessments would also be appropriate in student accommodation such as that occupied by Samantha Macdonald.
” Source location Samantha MacDonald · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of bedroom window restrictors to resist determined efforts to open windows
Wider context from the report “Samantha Macdonald jumped from the window of her bedroom on the 14th floor of her student accommodation in Salford. The window was not required to be used as a fire exit because it was too high. The window was fitted with a device that restricted the distance for which it would open. Evidence was heard that the device complied with the relevant British Standard and Planning regulations. If it had been in good working order it would have prevented the window from opening sufficiently to allow Samantha’s exit. It was, however, broken. Evidence revealed that the device could be broken by the application of force without the use of any tool. It was not possible to discover exactly when the device had been broken although it had been working during Samantha’s tenancy. Similar devices fitted to other bedrooms in the building had been found to be broken from time to time. The building is a non-smoking building that is entirely devoted to student accommodation, and witnesses believed that the devices had probably been broken so that students smoking in their rooms could avoid detection. Evidence was heard that in accommodation occupied by adults who might be determined to forcibly defeat window restrictors, for example in a healthcare setting, risk assessments were recommended to be reviewed and consideration given to replacing restrictors with more substantial or robust devices, and /or adding a second restrictor to better resist determined efforts to open the window , thus lessening the risk of persons falling either accidentally or otherwise. It is considered that such assessments would also be appropriate in student accommodation such as that occupied by Samantha Macdonald.
” Source location Samantha MacDonald · Prevention of Future Deaths report
Open source report
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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 Write to UUK and GuildHE by early July, urging higher education institutions to improve student accommodation safety and addressing risk assessments and robust window restrictors.
Verbatim wording from the response “However, my Department proposes to write to UUK, whose members consist of Vice-Chancellors, and GuildHE, a representative body for higher education providers, by early July, to ask them to ensure that HEIs are doing all they can to ensure the safety of students in such accommodation. In that letter we will also raise the points you have made concerning risk assessment and replacing window restrictors with more robust devices.” Source location 2016-0036-Response-by-Department-fro-Business-Innovation-and-Skills
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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 Enforce a signed student rule prohibiting interference with or removal of window restrictors.
Verbatim wording from the response “• Included a specific prohibition in ‘The Village Rules’, which students have to sign up to when renting a property. This states: “Window opening restrictor system is for your safety and must not be interfered with or removed. …Violation of this policy may, at the discretion of Village management, result in disciplinary action and a fine.”” Source location 2016-0036-Response-by-Campus-Living-Villages
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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 Inspect window restrictors each student term and before new intake, repairing damage and notifying students of sanctions where necessary.
Verbatim wording from the response “• Carried out checks of the latest each student term and prior to new student intake in September, including specific checks on window restrictors. Where window restrictors had been damaged or tampered with, CLV fixed the restrictors and issued a letter to the student concerned informing them of the potential for fines and/or disciplinary action should they break the window restrictor again.” Source location 2016-0036-Response-by-Campus-Living-Villages
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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 daily external checks for overcome window restrictors, taking action against students and reinstating restrictors when issues are identified.
Verbatim wording from the response “In relation to risks associated with accidental falls, associated with broken or damaged restrictors, or those which are ineffective for any other reason (e.g. opened for window purposes), additional steps have now been put in place on top of those in place at the time of incident. These include:” Source location 2016-0036-Response-by-Campus-Living-Villages
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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 Display warnings and develop separate safety procedures when work requires removal of window restrictors.
Verbatim wording from the response “• When work is taking place at CLV properties which requires the removal of window restrictors, warning signs are put in place and separately safety procedures are developed.” Source location 2016-0036-Response-by-Campus-Living-Villages
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Higher education institutions, rather than Government, are responsible for their own student-accommodation processes and procedures, including adherence to safety law.
Verbatim wording from the response “I should explain that Higher Education Institutions (“HEIs”) are independent and autonomous from Government, and are thus responsible for their own processes and procedures. In preparing this response, my officials have consulted with organisations in the higher education sector and other interested parties, but ultimately it is the responsibility of the HEIs themselves to adhere to the law.” Source location 2016-0036-Response-by-Department-fro-Business-Innovation-and-Skills
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The risk that force could break compliant window restrictors and cause accidental falls is considered eliminated and controlled by existing restrictors.
Verbatim wording from the response “We have specifically considered the suggestion made at inquest that the application of force (rather than use of a tool) could result in window restrictors breaking. In the context of accidental falls, this has been considered and eliminated as a real risk and one that it is controlled through the use of restrictors complying with BS EN 14351.” Source location 2016-0036-Response-by-Campus-Living-Villages
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Additional or more robust window restrictors are not considered the most effective or appropriate control for deliberate falls in a normal university setting.
Verbatim wording from the response “We have considered the comments made in your Regulation 28 report about the potential use of secondary restrictors and/or more robust devices. As set out at the start of this report, we do not consider CLV to have the same risk profile or duties (and powers) of a healthcare organisation.” Source location 2016-0036-Response-by-Campus-Living-Villages
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.