Recurring concern

Failure to ensure staff competence in fire safety and evacuation

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First reported 8 Jun 2016•Latest report 19 Apr 2026

Definition

What this concern includes

Includes failures to train, assess, verify, support or otherwise assure the competence of staff or other personnel responsible for fire safety, evacuation or associated emergency procedures, including failures to ensure that responsibilities are competently adopted and implemented.

Not included

  • Excludes deficiencies in fire-risk assessment, fire detection, alarms, suppression, escape routes or physical premises protection where personnel competence is not the shared unsafe condition.
  • Excludes generic staff training or role-clarity deficiencies unrelated to fire safety or evacuation.
  • Excludes failures concerning evacuation of people unable to self-evacuate where the specific issue is the dedicated arrangements for assisting those people rather than general personnel competence.
  • Excludes failures to implement fire-safety measures after competent personnel have been established, unless competence assurance is also deficient.
Reports
6

Distinct published reports

Individual concerns
7

A report can raise multiple concerns

Date range
2016–2026

First to latest report issue date

Stated actions
9

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.

London Fire Brigade2
National Fire Chiefs Council2
British Standards Institution1
Care Quality Commission1
Chartered Trading Standards Institute1
Chief Fire and Rescue Adviser1
Department for Business, Energy & Industrial Strategy1
Devon County Council1
Guinness Care and Support Limited1
Health and Safety Executive1
Home Office1
Hotpoint UK Appliances Limited1
JHS Contracts Limited1
Liaise (London) Limited1
Local Government Association1

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. West London

    AI-generated summary

    Paul HUTCHINSON · 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

    Paul HUTCHINSON died of burns after setting himself alight while smoking in his Extra Care Sheltered Accommodation on 21 January 2025. The report raised concerns about the lack of specific requirements for individual fire risk and evacuation assessments, non-standardised staff training, and whether fire risk assessments adequately considered vulnerable residents who may be unable to self-evacuate.

    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 standardise staff training on evacuation, alarm, telecare and fire suppression procedures

    Wider context from the report

    “2. Staff training is not standardised for ECSA (or sheltered accommodation more generally) and may not include, for example, evacuation strategy, emergency evacuation plans, the use of telecare/fire alarm system and fire suppression systems. ”

    Source location

    Paul HUTCHINSON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  2. Inner South London

    AI-generated summary

    Mr Tomas Ceida · 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 Tomas Ceida died in hospital after a fire at a site being used as a nightclub, where construction work was underway and staff and operatives sometimes slept overnight. The jury identified concerns including the unsuitable acoustic wall, unsafe and inadequately supervised hot works, and failures to agree and communicate fire-safety responsibilities, provide adequate fire alerts, conduct an orderly evacuation, and complete adequate fire-risk assessments. The coroner also raised concerns about regulatory follow-up, communication between authorities, documentation of contractor roles, and public and contractor awareness of fire-safety duties.

    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 assurance that fire safety and evacuation responsibilities are competently adopted and implemented

    Wider context from the report

    “• Although steps were taken by JHS to mitigate fire risks through the subsequent management and supervision of hot works, there is no evidence of what steps are taken by JHS individuals now in the building trade in each case to ensure the responsibility for fire safety and evacuation has been competently adopted and implemented. ”

    Source location

    Mr Tomas Ceida · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  3. East London

    AI-generated summary

    Ashlie Timms · 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

    Ashlie Timms, a 46-year-old woman living in supported accommodation, died on 20 April 2018 after a fire started when fabric materials came into contact with a portable fan heater. Staff delayed calling the emergency services, did not evacuate her, and the fire safety arrangements, alarm system, evacuation procedures and door lock were identified as concerns.

    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 ensure staff competence in fire evacuation procedures

    Wider context from the report

    “1. The operator of the premises failed to ensure that staff on duty were competent to carry out a fire evacuation. Despite reflection and remediation in policies, processes and training, multiple staff members who gave evidence to the inquest, remained unable to describe the proper action to take in the event of a fire alarm. ”

    Source location

    Ashlie Timms · Prevention of Future Deaths report
    Page 3 · 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

    Report the staff competency concern to relevant committees to encourage debate and pursue improved outcomes.

    Verbatim wording from the response

    “The NFCC represent FRS on various British Standards Institute (BSI) committees and other groups such as National Social Housing Fire Safety Group.”

    Source location

    Response from National Fire Chiefs Council
    Page 2 · response
    Published 29 April 2022

    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 annual face-to-face fire warden training to all employees, including new joiners at the next available session.

    Verbatim wording from the response

    “26. Face to face fire safety training is now provided to staff. This training is provided annually by Pinnacle and is delivered at each premises. The training covers, amongst other things, evacuation routes and procedures, fire drills and fire safety measures. A copy of the training handbook provided to staff as part of that training is attached.”

    Source location

    Response from Kennedys
    Page 2 · response
    Published 29 April 2022

    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 premises-specific induction training and annual refresher training to permanent and agency staff.

    Verbatim wording from the response

    “27. Specific induction training, tailored to each of Sequence Care’s premises, is also provided to the permanent and agency staff assigned to work there. This training is delivered to staff by either the registered manager or one of the deputy managers. The training ensures staff are familiar with and have read the following: fire safety policy, accidents and incidents procedure, EMG Response Plan and support plans/risk assessments/PEEPs for service users at that premises. Completion of this training is confirmed in the permanent and agency staff checklists attached...Staff refresher training is also provided annually.”

    Source location

    Response from Kennedys
    Page 2 · response
    Published 29 April 2022

    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 annual fire-safety competency assessments using the revised checklist and reassess staff against it.

    Verbatim wording from the response

    “28. In addition, a competency assessment is carried out on an annual basis by either the registered manager or deputy manager (who are also to be trained by SOCOTEC in how to carry out this assessment) in the form of question and answer sessions, on which staff”

    Source location

    Response from Kennedys
    Page 2 · response
    Published 29 April 2022

    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

    Fire precaution issues should be examined by technical committee FSH/14, which is responsible for relevant building fire-safety standards.

    Verbatim wording from the response

    “The committee experts believe the committees which should examine the issues more closely are:”

    Source location

    Response from British Standards Institution
    Page 1 · response
    Published 29 April 2022

    Open published response
  4. Inner West London

    AI-generated summary

    Mrs Elizabeth Marion Griffin · 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

    Mrs Elizabeth Marion Griffin, who was wheelchair bound due to advanced multiple sclerosis, was alone at home in bed when a dishwasher fire started on 14 July 2017. She activated her pendant alarm, but the responder did not recognise the smoke alarm, could not communicate effectively with her, and did not call the fire brigade; Mrs Griffin later died in hospital on 21 August 2017 from smoke inhalation injuries and bronchopneumonia. The concerns included delayed action by the dishwasher manufacturer, lack of appliance-owner registration and contact, and shortcomings in telecare arrangements, including unlinked fire alarms, responder training, communication, and escalation procedures.

    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

    Inadequate staff training on standards-compliant fire-alarm response

    Wider context from the report

    “10. That telecare systems providers and WWA in particular, train their staff on the appropriate response to the activation of a fire alarm and that this should be according to the standards laid down by the British Standards Institute. ”

    Source location

    Mrs Elizabeth Marion Griffin · Prevention of Future Deaths report
    Page 4 · 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 train staff to recognise and escalate linked and unlinked fire-alarm sounds

    Wider context from the report

    “11. That telecare systems providers and WWA in particular, train their staff as to what fire alarm activation sounds like whether from a linked or unlinked alarm and that they should call the fire brigade appropriately if they are heard by the responder to be activated. ”

    Source location

    Mrs Elizabeth Marion Griffin · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report
  5. Plymouth, Torbay and South Devon

    AI-generated summary

    Kenneth Arthur Brincombe · 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

    Kenneth Arthur Brincombe, an 81-year-old man with severe mobility and visual impairments, accidentally set fire to himself while smoking on 31 October 2016 and died from his burns. Concerns included carers facilitating smoking without supervision, insufficient training to assess fire hazards, and smoke detectors that would not alert a fire station or enable him to take evasive action.

    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 carer training to assess household and appliance fire hazards

    Wider context from the report

    “(2) In evidence the carer confirmed that the carers were responsible for maintaining a safe environment, but had no training in how to assess whether the house and the appliances were safe or whether they posed a fire hazard. ”

    Source location

    Kenneth Arthur Brincombe · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Use Care Act assessments, risk-based analysis and care planning to identify and address fire risks through support or assistive technology.

    Verbatim wording from the response

    “6. The care management processes and documentation that support the assessment and support responsibilities under the Care Act, include risk based analysis against the Care Act eligibility outcomes as set out in Regulation 2(2) of the Care and Support (Eligibility Criteria) Regulations 2014:”

    Source location

    Kenneth-BRINICOMBE-Response
    Page 2 · response
    Published 25 August 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Share incident learning and alerting options with the Provider Engagement Network, including reminders about robust risk assessment and escalation of concerns.

    Verbatim wording from the response

    “d) Learning from the incident, options and solutions will be shared with the Provider Engagement Network (for independent service providers) to include a reminder for the need to undertake robust risk assessments and alert the relevant social care team should ongoing concerns arise. By end April 2018”

    Source location

    Kenneth-BRINICOMBE-Response
    Page 4 · response
    Published 25 August 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide carers with induction health and safety training covering risk assessment, hazardous substances and fire safety.

    Verbatim wording from the response

    “All of our carers receive health and safety training during induction. This includes:”

    Source location

    Kenneth-BRINICOMBE-Response2
    Page 1 · response
    Published 25 August 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Refresh carers’ health and safety training every three years.

    Verbatim wording from the response

    “All of our carers receive health and safety training during induction. This includes:”

    Source location

    Kenneth-BRINICOMBE-Response2
    Page 1 · response
    Published 25 August 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Invite the fire brigade’s Community Safety Champion to brief carers between formal training cycles on available support and fire risks.

    Verbatim wording from the response

    “This training is refreshed every 3 years. In between this training we invite the Community Safety Champion in from the fire brigade, where they give a talk to the carers about what the fire service can do to help and support, when to contact them and what risks to look for.”

    Source location

    Kenneth-BRINICOMBE-Response2
    Page 2 · response
    Published 25 August 2018

    Open published response
  6. Manchester City

    AI-generated summary

    Stephen Alan HUNT · 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

    Stephen Alan Hunt, a firefighter, died after entering a fire at Paul's Hair and Beauty World in Manchester on 13 July 2013. He was found inside the premises after suffering heat exhaustion and hypoxia. The principal concerns included failures in communication and handover, misinterpretation of instructions, loss of telemetry and radio communications, inadequate fire risk assessments and fire safety measures, and decisions affecting firefighter safety.

    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 means for responsible persons to verify fire risk assessor competence

    Wider context from the report

    “(9) It is suggested that the Secretary of State for the Home Department considers measures to ensure that: fire risk assessors are adequately trained and qualified so as to be competent in the role, and the responsible person has the means to verify the competence of any person holding themselves out to be a fire risk assessor. ”

    Source location

    Stephen Alan HUNT · Prevention of Future Deaths report
    Page 10 · concerns

    Open source report
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Data last updated 7 September 2026