Recurring concern

Failure to ensure accountable and proactive repair of accommodation hazards for vulnerable residents

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First reported 3 Oct 2018•Latest report 27 Mar 2019

Definition

What this concern includes

Includes failures of arrangements for identifying, assigning responsibility for, initiating, coordinating or completing repairs needed to make accommodation safe for vulnerable residents, including privately rented accommodation and supported or welfare-managed residential accommodation where residents may be unable to recognise or report hazards or obtain repairs themselves.

Not included

  • Excludes ordinary property-maintenance delays or defects where no vulnerable-resident safety context or failure of accountable repair arrangements is identified.
  • Excludes generic housing governance, communication or staffing deficiencies unless they directly impair proactive identification, ownership or completion of accommodation-safety repairs.
  • Excludes hazards in public infrastructure, vehicles, healthcare equipment or other non-accommodation settings.
  • Excludes isolated physical accommodation hazards where no deficiency in the responsibility, initiation or completion of the repair process is asserted.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2018–2019

First to latest report issue date

Stated actions
3

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Diocese of Northampton2
East Coast Community Healthcare C.I.C.2
Archdiocese of Westminster1
Department of Health and Social Care1
Home Office1
Local Government Association1
London Borough of Lewisham1
National Police Chiefs’ Council1
Patrick Stead Hospital1

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.

  1. Inner South London

    AI-generated summary

    Ms Donna Williamson · 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

    Donna Williamson, a 44-year-old woman with mental health, alcohol dependence, mobility and domestic abuse vulnerabilities, died from stab wounds to the chest after being assaulted with a knife by her ex-partner. The principal concerns included the failure to secure her insecure door, failure to inform her that the suspect had been released on bail, and weaknesses in the MARAC process for protecting chaotic and non-engaging individuals.

    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 to assign responsibility for repairing and securing doors in privately rented accommodation

    Wider context from the report

    “1. No one agency took responsibility for repairing and securing the door. The detailed evidence is attached in an Appendix. Additionally a local authority officer gave evidence that the local authority did not realize that they had a duty to repair it if the landlord did not. Additionally it was reported that there was a local scheme that provided a service for disabled people which was not contacted. Local authorities may need wider awareness of how to resolve such problems for privately renting vulnerable tenants. ”

    Source location

    Ms Donna Williamson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Responsibility for repairing and securing the private rented property’s front door lies with the local authority officer if the landlord does not act.

    Verbatim wording from the response

    “With regards to concern (1) regarding the repairing and securing of the front door of private rented accommodation, your report identifies a duty on the local authority officer to repair the door if the landlord did not. I understand that LGA officers have requested additional information from your office about which legislation this duty falls under. Clarity on this issue will help us to raise awareness of how to resolve such problems for privately renting vulnerable tenants.”

    Source location

    2019-0111-Responses
    Page 3 · response
    Published 9 June 2019

    Open published response

  2. Suffolk

    AI-generated summary

    Brian Alban Frost · 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

    Brian Alban Frost, a 92-year-old retired Roman Catholic priest who lived alone, died after an unwitnessed fall at home on 30 June 2018, sustaining severe head injuries. The report raised concerns about loose kitchen floor tiles presenting a trip hazard and about the inadequacy of welfare checks and health-and-safety risk assessments for retired clergy living in diocesan properties.

    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

    Reliance on residents or informal third parties to identify hazards and request accommodation repairs

    Wider context from the report

    “5. It was heard in evidence that the diocese had a system of visits in place from the Clergy Welfare Officer and, if the retired priest was subject to a ‘covenant of care’ a Safeguarding Coordinator. Details of visits to Canon Frost’s home were recorded as taking place in October 2010, December 2010, January 2011, July 2011, May 2012, January 2013, April 2014, August 2014, July 2016 and October 2017. 6. In reports compiled in relation to these visits no mention is made of any health and safety or risk assessment activity being undertaken. 7. A note from the October 2017 visit (11 months prior to Canon Frost’s death) provides details of a recent fall in which Canon Frost fractured his hip, the fact he now used a walking frame and that his bedroom had been moved down stairs (following a visit from the local NHS Community Health Team). The property manager offered Canon Frost a visit from the Clergy Welfare Coordinator but this was declined. 8. Despite identifying major factors regarding Canon Frost’s mobility and increasing frailty, again no mention is made of any health and safety or risk assessment activity being undertaken. 9. Giving the nature of the residents of these properties there is a degree of certainty that other ‘grace and favour’ residents will lose (or have already lost) the physical ability or the mental capacity to maintain their accommodation in a safe condition. On the evidence heard the system of welfare checks was not sufficiently robust and there was no independent assessment for health and safety risks. It was apparent that the current system required the resident themselves, a family member or some other third party to raise such concerns when the fabric of the building is deteriorating. The resident themselves would then need to request for the work to be undertaken. 10. Dependant on the personal circumstance of each retired member of the clergy this system appears flawed, as it relies solely on the resident retaining the mental capacity and/or the physical ability to identify that a hazard exists and then make their own request for repairs. Without doubt, the welfare system currently in place failed to identify and remedy the fact that an obvious and serious trip hazard risk was present in Canon Frost's home. ”

    Source location

    Brian Alban Frost · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Suffolk

    AI-generated summary

    Brian Alban Frost · 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

    Brian Alban Frost died after an unwitnessed fall at home in which he sustained severe head injuries. The report identifies loose kitchen floor tiles as a serious trip hazard and raises concerns that welfare checks for retired priests living in diocesan properties did not include independent health and safety or risk assessments, allowing hazards to remain unidentified and unrepaired.

    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

    Reliance on residents or third parties to identify hazards and request repairs

    Wider context from the report

    “9. Giving the nature of the residents of these properties there is a degree of certainty that other ‘grace and favour’ residents who lose (or have already lost) the physical ability or the mental capacity to maintain their accommodation in a safe condition. On the evidence heard the system of welfare checks was not sufficiently robust and there was no independent assessment for health and safety risks. It was apparent that the current system required the resident themselves, a family member or some other third party to raise such concerns when the fabric of the building is deteriorating. The resident themselves would then need to request for the work to be undertaken. 10. Dependant on the personal circumstance of each retired member of the clergy this system appears flawed, as it relies solely on the resident retaining the mental capacity and/or the physical ability to identify that a hazard exists and then make their own request for repairs. Without doubt, the welfare system currently in place failed to identify and remedy the fact that an obvious and serious trip hazard risk was present in Canon Frost’s home. 11. Given that this is the case I am concerned that other residents of ‘grace and favour’ homes provided by the Bishop of each dioceses, may now also be living in premises that may no longer be considered safe for their occupation. ”

    Source location

    Brian Alban Frost · 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

    Have a diocesan surveyor accompany the Clergy Welfare Officer on at least annual visits to retired priests.

    Verbatim wording from the response

    “• All Priests will continue to receive at least annual visits from the Diocesan Clergy Welfare Officer, but the Welfare Officer will be joined on those visits by one of the Diocesan Surveyors;”

    Source location

    2018-0362-Response
    Page 3 · response
    Published 26 April 2019

    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 full internal, external, fabric, condition, and health and safety assessments informed by each priest’s health and mobility.

    Verbatim wording from the response

    “• The Surveyor will carry out a full external and internal assessment of the property’s fabric and condition, together with a Health and Safety Assessment informed by the advice of the Welfare Officer about the health and mobility of the Priest;”

    Source location

    2018-0362-Response
    Page 4 · response
    Published 26 April 2019

    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

    Discuss survey findings with the priest and organise, approve, and fund identified property or health and safety repairs through the surveyor.

    Verbatim wording from the response

    “• At the end of the survey the Surveyor, the Welfare Officer and the Priest will discuss the findings of the survey. Any repair works noted as being needed or recommended from a property or health and safety perspective will be agreed with the Priest and organised by the Surveyor, who will agree with the Priest suitable times for access and will manage and approve the works. The costs will be borne by the Diocese;”

    Source location

    2018-0362-Response
    Page 4 · response
    Published 26 April 2019

    Open published response

    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 Diocese considered family support and annual pastoral visits sufficient to identify accommodation safety issues, rather than requiring day-to-day welfare safeguarding.

    Verbatim wording from the response

    “It also had no other legal obligations in relation to the welfare of Canon Frost merely because he was a retired priest of the Diocese. While it did ensure that a yearly pastoral visit was made to him, it was not thereby assuming a day to day responsibility to safeguard his welfare while resident at ████████ ████████. As you know certain other financial provision was made but this did not bring with it an obligation to ensure, for example, that nothing about the internal fabric of the house presented a day to day risk.”

    Source location

    2018-0362-Response
    Page 3 · response
    Published 26 April 2019

    Open published response
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Data last updated 7 September 2026