Recurring concern

Unreliable fire-response instructions for residents

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First reported 27 Oct 2015•Latest report 16 Jun 2021

Definition

What this concern includes

Includes failures in resident-facing fire-response instructions for communal or residential accommodation, including inaccurate sequencing of emergency calls, unclear or unknown stay-put or evacuation guidance, and inadequate communication or review of those instructions.

Not included

Excludes fire alarms, emergency cords, telecare links and other detection or notification equipment where the resident-facing instruction process is not deficient.
Excludes physical evacuation routes, fire doors, sprinklers, barriers and building-design deficiencies unless they directly cause unclear or misleading resident fire instructions.
Excludes post-alarm resident checks, staff response and evacuation assistance after instructions have been communicated reliably.
Excludes generic fire-safety standards, staff training or premises risk assessments where resident-facing fire-response instructions are not the shared unsafe condition.

Reports: 2
Individual concerns: 3
Date range: 2015–2021
Stated actions: 12

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Bristol City Council1

Stoke-on-Trent City Council1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

16 Jun2021
Stoke-on-Trent and North Staffordshire
Concerns raised2
1. Lack of a plan to make residents aware of the “Stay Put” fire policy
2. Failure to ensure residents’ awareness of the “Stay Put” fire policy
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 12
1. Action
  Provide, translate, display and periodically redistribute Fire Safety Notices explaining the Stay Put Policy to residents and leaseholders.
  Stated by Stoke-on-Trent City CouncilStated completed
2. Action
  Communicate and verify understanding of the Stay Put Policy during tenancy visits using trained Housing Officers, scripted questions, declarations and documented checklists.
  Stated by Stoke-on-Trent City CouncilStated completed
3. Action
  Provide accessible fire-safety communication through translation, imagery, disability-adapted communication, interpreters and coordinated support for tenants requiring additional assistance.
  Stated by Stoke-on-Trent City CouncilStated completed
1. Action
  Use proactive telephone calls to discuss fire safety, check tenants’ understanding and update relevant records.
  Stated by Stoke-on-Trent City CouncilStated completed
2. Action
  Engage tenants through Tenant Board participation, community events, leaseholder newsletters, councillor surgeries and promoted fire-safety services.
  Stated by Stoke-on-Trent City CouncilStated completed
3. Action
  Require Housing Officers conducting Tenancy Audit Visits to complete enhanced training on communicating with tenants whose first language is not English.
  Stated by Stoke-on-Trent City CouncilStated planned
4. Action
  Develop a fire-safety and Stay Put video and question-and-answer materials for residents with different learning styles.
  Stated by Stoke-on-Trent City CouncilStated in progress
5. Action
  Post Fire Safety Notices through all leaseholder properties’ letterboxes and explain leaseholders’ responsibility to inform and educate sub-tenants.
  Stated by Stoke-on-Trent City CouncilStated planned
6. Action
  Review the frequency of fire-safety and Stay Put communications to leaseholders.
  Stated by Stoke-on-Trent City CouncilStated planned
7. Action
  Consider increasing targeted digital communications conveying the Stay Put Policy to residents in Stay Put Blocks.
  Stated by Stoke-on-Trent City CouncilStated planned
8. Action
  Explore the effectiveness of displaying additional communal notices explaining that Fire Safety Notices can be requested in other languages.
  Stated by Stoke-on-Trent City CouncilStated planned
9. Action
  Undertake more in-depth questioning of Stay Put Block tenants and use the resulting feedback to inform the fire-safety communication strategy.
  Stated by Stoke-on-Trent City CouncilStated planned
AI-generated summary

Zainab Adam Bargo Hashim and Tafaoul Abdullilia Abdulkarim · 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

Zainab Adam Bargo Hashim died on 2 October 2017 and Tafaoul Abdullilia Abdulkarim died two days later after inhaling fire fumes while attempting to flee a fire through the communal area of their block of flats. The report identified concern that residents were unaware of the council’s “Stay Put” policy and that the policy’s communication had not been changed after the incident, creating a risk of future deaths.

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 plan to make residents aware of the “Stay Put” fire policy
Wider context from the report
“During the inquest Stoke-on-Trent City Council gave evidence to the effect that, within the properties that they own (they have some 19000 properties), if the properties are blocks of flats, there is a “Stay Put” policy in place. Residents, so long as the fire is not within their property, should stay in their flats, alert the appropriate emergency service, and wait for help. It became apparent during the course of the inquest that no resident at the Ringland Close block of flats knew of the existence of this policy. Stoke-on-Trent City Council gave evidence to the effect that to communicate this policy to their residents they do so in exactly the same way that they had before the fire at Ringland Close. There are fire notices in the communal areas of the flats and in September 2017, a tenant newsletter was posted through all letterboxes at relevant blocks of flats. This newsletter reiterated the “Stay Put” policy. During this particular incident no residents had stayed within their property. No residents were aware of the “Stay Put” policy. Evidence was heard that, had Zainab and Tafaoul, stayed within ████████ the two deaths would not have occurred. Stoke-on-Trent City Council gave evidence that, since the fire, they have not changed the way the policy is communicated to residents of their properties. Therefore, the lack of awareness of a policy in place, and lack of plan to make residents aware, in the event of a fire leads me to conclude that there is a risk of future deaths occurring. ”
Source location
Zainab Adam Bargo Hashim and Tafaoul Abdullilia Abdulkarim · Prevention of Future Deaths report
Page 2 · concerns
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 to ensure residents’ awareness of the “Stay Put” fire policy
Wider context from the report
“During the inquest Stoke-on-Trent City Council gave evidence to the effect that, within the properties that they own (they have some 19000 properties), if the properties are blocks of flats, there is a “Stay Put” policy in place. Residents, so long as the fire is not within their property, should stay in their flats, alert the appropriate emergency service, and wait for help. It became apparent during the course of the inquest that no resident at the Ringland Close block of flats knew of the existence of this policy. Stoke-on-Trent City Council gave evidence to the effect that to communicate this policy to their residents they do so in exactly the same way that they had before the fire at Ringland Close. There are fire notices in the communal areas of the flats and in September 2017, a tenant newsletter was posted through all letterboxes at relevant blocks of flats. This newsletter reiterated the “Stay Put” policy. During this particular incident no residents had stayed within their property. No residents were aware of the “Stay Put” policy. Evidence was heard that, had Zainab and Tafaoul, stayed within ████████ the two deaths would not have occurred. Stoke-on-Trent City Council gave evidence that, since the fire, they have not changed the way the policy is communicated to residents of their properties. Therefore, the lack of awareness of a policy in place, and lack of plan to make residents aware, in the event of a fire leads me to conclude that there is a risk of future deaths occurring. ”
Source location
Zainab Adam Bargo Hashim and Tafaoul Abdullilia Abdulkarim · Prevention of Future Deaths report
Page 2 · 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
Provide, translate, display and periodically redistribute Fire Safety Notices explaining the Stay Put Policy to residents and leaseholders.

Verbatim wording from the response
“All residents in Stay Put Blocks receive a copy of the Fire Safety Notice (Appendix A) produced in partnership with Staffordshire Fire and Rescue Service which sets out concisely what they should do in the event of a fire.”

Source location
2021-0205-Response-from-Stoke-on-Trent-City-Council_Published
Page 1 · response
Published 28 June 2021
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
Communicate and verify understanding of the Stay Put Policy during tenancy visits using trained Housing Officers, scripted questions, declarations and documented checklists.

Verbatim wording from the response
“The Stay Put Policy is verbally communicated to tenants of the Stay Put Blocks when an annual Tenancy Audit Visit is carried out by Housing Officers. Housing Officers are trained on Fire Safety Awareness and how to communicate the Stay Put Policy. This training is refreshed annually.”

Source location
2021-0205-Response-from-Stoke-on-Trent-City-Council_Published
Page 1 · response
Published 28 June 2021
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
Provide accessible fire-safety communication through translation, imagery, disability-adapted communication, interpreters and coordinated support for tenants requiring additional assistance.

Verbatim wording from the response
“Where English is not a tenant’s first language, the Lettings staff will employ the services of a translator to attend Sign Up Visits with them to translate the Stay Put Policy (amongst other things) and to interpret any questions asked. This service is free of charge to tenants. This process is recorded in a recently developed Fire Safety Advice Check List. If a tenant requires ongoing translation support at Tenancy Audit Visits this is provided by arranging for the attendance of the family and friends who speak English or if necessary the services of a professional translator will again be provided by the Council.”

Source location
2021-0205-Response-from-Stoke-on-Trent-City-Council_Published
Page 2 · response
Published 28 June 2021
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
Use proactive telephone calls to discuss fire safety, check tenants’ understanding and update relevant records.

Verbatim wording from the response
“In addition to the above, Proactive Calls to tenants have been introduced whereby the Council will attempt to contact all tenants by telephone and discuss fire safety and to check understanding about the Stay Put Policy where appropriate amongst other matters. This method of communication is also used to update our records of any changes in the tenant’s details, and listen to tenant’s views on how safe and secure they feel.”

Source location
2021-0205-Response-from-Stoke-on-Trent-City-Council_Published
Page 3 · response
Published 28 June 2021
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
Engage tenants through Tenant Board participation, community events, leaseholder newsletters, councillor surgeries and promoted fire-safety services.

Verbatim wording from the response
“The Council has a Tenant Board which represents the diverse demographic residing in Council owned and managed social housing in Stoke-on-Trent, with the purpose of giving tenants a voice on key aspects of housing management. The seven Tenant Board Members are involved in how the Stay Put Policy is communicated and recently participated in trialling the Proactive Calls.”

Source location
2021-0205-Response-from-Stoke-on-Trent-City-Council_Published
Page 3 · response
Published 28 June 2021
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
Require Housing Officers conducting Tenancy Audit Visits to complete enhanced training on communicating with tenants whose first language is not English.

Verbatim wording from the response
“Housing Officers undertaking Tenancy Audit Visits will be required to undertake enhanced training on communicating with tenants who don’t speak English as a first language.”

Source location
2021-0205-Response-from-Stoke-on-Trent-City-Council_Published
Page 4 · response
Published 28 June 2021
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
Develop a fire-safety and Stay Put video and question-and-answer materials for residents with different learning styles.

Verbatim wording from the response
“We are also in the formative stages of developing a video on fire safety and Stay Put and a series of questions and answers to help to communicate the Stay Put Policy to residents with different types of learning styles. It is intended that the video will be watched during the application process for Council housing by those who have been offered a Council property and be available to all tenants.”

Source location
2021-0205-Response-from-Stoke-on-Trent-City-Council_Published
Page 4 · response
Published 28 June 2021
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
Post Fire Safety Notices through all leaseholder properties’ letterboxes and explain leaseholders’ responsibility to inform and educate sub-tenants.

Verbatim wording from the response
“Fire Safety Notices will be posted through the letterbox of all leaseholder properties and leaseholders will be made aware that it is their responsibility as landlord to make sure that their sub-tenants are aware of the Stay Put Policy and understand it. This will start with immediate effect.”

Source location
2021-0205-Response-from-Stoke-on-Trent-City-Council_Published
Page 4 · response
Published 28 June 2021
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 the frequency of fire-safety and Stay Put communications to leaseholders.

Verbatim wording from the response
“The Council will review the frequency of how it communicates with leaseholders around fire safety and Stay Put.”

Source location
2021-0205-Response-from-Stoke-on-Trent-City-Council_Published
Page 4 · response
Published 28 June 2021
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
Consider increasing targeted digital communications conveying the Stay Put Policy to residents in Stay Put Blocks.

Verbatim wording from the response
“The Council will consider increasing the use of targeted digital communication methods to convey the message of Stay Put to residents in Stay Put Blocks e.g. including this information in mast banners, signage boxes, tenants e bulletins and rent bills.”

Source location
2021-0205-Response-from-Stoke-on-Trent-City-Council_Published
Page 4 · response
Published 28 June 2021
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
Explore the effectiveness of displaying additional communal notices explaining that Fire Safety Notices can be requested in other languages.

Verbatim wording from the response
“The Council is also exploring the effectiveness of also displaying an additional notice in communal areas of all Stay Put Blocks explaining that the Fire Safety Notice can be requested in other languages.”

Source location
2021-0205-Response-from-Stoke-on-Trent-City-Council_Published
Page 4 · response
Published 28 June 2021
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
Undertake more in-depth questioning of Stay Put Block tenants and use the resulting feedback to inform the fire-safety communication strategy.

Verbatim wording from the response
“More in depth questioning will be undertaken of tenants in Stay Put Blocks, of their understanding of the Stay Put Policy. Feedback obtained will be used to inform the Council’s communication strategy around fire safety going forward.”

Source location
2021-0205-Response-from-Stoke-on-Trent-City-Council_Published
Page 4 · response
Published 28 June 2021
Open published response
27 Oct2015
Avon
Concerns raised1
1. Failure of fire instructions to require residents to dial 999 first
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mr. George Hines · 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

Mr. George Hines, who lived in sheltered accommodation, died from carbon monoxide toxicity following a fire at his home on 23 October 2014. The concerns included an unconnected bedroom pull-cord, lack of regular inspection and maintenance of alarm and smoke-detector systems, smoke detection that did not alert the emergency control room or communal areas, and resident fire instructions that prioritised pulling the cord over calling 999.

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 fire instructions to require residents to dial 999 first
Wider context from the report
“The current advice to residents on discovering a fire is to leave their flat and alert the emergency services by pulling the emergency cord in the communal area or in a neighbour's flat. The Inquest heard evidence there was no pull-cord in the communal area of this building. The residents are also instructed that the alternative to pulling the five cord was that they should dial 999. Instructions to residents to pull the cord first may give a false sense of security that the emergency services have been alerted even if they receive no audible response from the ECR. The Council should revise its instructions to residents in the event of fire generally and specifically that they are instructed to dial 999 first before taking any other action. ”
Source location
Mr. George Hines · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Lack of a plan to make residents aware of the “Stay Put” fire policy

Failure to ensure residents’ awareness of the “Stay Put” fire policy

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.12

Concerns raised1

Failure of fire instructions to require residents to dial 999 first

Actions described in response 12