Recurring concern

Failure of fire detection systems to reliably alert and trigger emergency response

First to latest report 25 Aug 2017 — 16 Jun 2026

Reports that mention this concern
6
Times this concern has been raised
10
Stated actions linked to this concern
26

What this concern includes

Includes failures to distinguish fault and fire signals, operate audible or visual alerts, transmit alarms, notify responsible staff, initiate an emergency call or escalate after a fire condition is detected.

What is not included
  • Excludes absence, coverage or detection-timing of prison in-cell fire detection when no alert or escalation failure is asserted; those belong to the prison fire-detection parent.
  • Excludes general fire prevention, evacuation, suppression, staffing or training where alarm and escalation are not deficient.
  • Excludes response failures after a clear and reliable fire alarm has been received unless part of the same escalation system.
  • Excludes non-fire notification systems.

Reports and published responses 6 reports

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

  1. Birmingham and Solihull

    AI-generated summary

    Trevor John Ridd · 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 04 January 2026, Trevor John Ridd’s bedding caught fire while he was unable to leave his bed because of mobility issues. The sprinkler system activated, but its fault and fire signals were treated as one incident and no 999 call was raised by the Alarm Receiving Centre operator; Mr Ridd was later found with burns and died after suffering cardiac arrest. Concerns included the handling and wording of the two signals, operator training and briefing, and the testing and maintenance of the sprinkler system.

    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 operators distinguish fault and fire notifications and escalate appropriately

    Wider context from the report

    “2. It remains unclear as to why the individual operator treated both signals as being part of the same incident and failed to raise a 999 call; it is not clear how a fault notification works alongside a fire notification. ”

    Source location

    Trevor John Ridd · 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

    Lack of a clear procedure for handling fault and fire signals received in quick succession

    Wider context from the report

    “1. It is not clear why the sprinkler system generated two signals (one ‘fault’ and one ‘fire’) within seconds of one another and what the procedure was for handling this. ”

    Source location

    Trevor John Ridd · 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 ensure correct ordering of sprinkler fault and fire signals

    Wider context from the report

    “3. It is not clear what training or instruction individual operators receive in relation to how they are to deal with situations where two notification signals are received in quick succession. It is also unclear what information alerts (if any) are communicated to individual operators in respect of the property from which the signals are received i.e. was it noted that the signals came from Mr Ridd’s property who was bed-bound and a known smoker with severe COPD where there had been a previous incident where he had singed his blanket from smoking in his bed? 4. The evidence at Inquest suggested that the two signals received were the wrong way around however it was not clear why this was and whether this has since been rectified. 5. There is no evidence of regular testing and maintenance of the sprinkler system. 6. It is not clear what individual operators have been ‘briefed’ on post-incident with regards to situations where two notification signals are received in quick succession from the same property. ”

    Source location

    Trevor John Ridd · Prevention of Future Deaths report
    Page 4 · 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

    Update procedures so duplicate or successive notifications are individually acknowledged, assessed, actioned and escalated.

    Verbatim wording from the response

    “Following the incident, all procedures relating to the management of duplicate notifications and multiple alerts from the same site have been reviewed and updated. The revised procedures now make explicit that each notification must be individually acknowledged, assessed, actioned and closed, regardless of whether another notification has already been received from the same property.”

    Source location

    Response from Birmingham City County
    Page 3 · response
    Published 14 August 2026

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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

    Issue written instructions and deliver verbal briefings reinforcing separate assessment of each notification and verification of its wording and classification.

    Verbatim wording from the response

    “Immediately following the incident, management issued written instructions to all operators reinforcing that duplicate notifications from the same site must not be assumed to relate to an existing incident and that each notification must be reviewed and actioned separately. This requirement was further reinforced through verbal briefings at the commencement of shifts and more recently through individual recorded discussions with all call handling operators.”

    Source location

    Response from Birmingham City County
    Page 4 · response
    Published 14 August 2026

    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

    Add mandatory electronic pop-up reminders requiring operators to acknowledge review of notifications before continuing call handling.

    Verbatim wording from the response

    “• Electronic Pop-Up notifications created in the system as a reminder on every call to review all notifications even if they are received in close succession from the same property. Each ‘Pop-Up’ has to be acknowledged & closed by operators before they can continue to handle that or any further calls.”

    Source location

    Response from Birmingham City County
    Page 4 · response
    Published 14 August 2026

    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

    Obtain written confirmation from all operators that they have read, understood and will comply with revised procedures.

    Verbatim wording from the response

    “• Written confirmation is being obtained from all operators to confirm they have read, understood and will comply with the revised procedures. This assurance exercise will be completed by the end of August 2026.”

    Source location

    Response from Birmingham City County
    Page 4 · response
    Published 14 August 2026

    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

    Continue individual operator discussions through supervision to reinforce learning and maintain compliance with revised procedures.

    Verbatim wording from the response

    “• Further individual discussions have subsequently been undertaken and are ongoing and being formally recorded with each operator.”

    Source location

    Response from Birmingham City County
    Page 4 · response
    Published 14 August 2026

    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 training and operator competency arrangements, embedding learning on alarm distinctions, individual assessment and escalation through procedures, briefings and supervision.

    Verbatim wording from the response

    “In addition to the procedural changes outlined above, the organisation recognises that effective operator training is fundamental to the safe operation of the Alarm Receiving Centre. Training requirements and operator competency arrangements have therefore been reviewed following this incident to ensure staff clearly understand the distinction between different alarm types, the need to assess each notification and the requirement to follow escalation procedures regardless of whether another notification from the same property is already being managed. This learning has been embedded through written procedures, management briefings, individual supervision and staff acknowledgement processes.”

    Source location

    Response from Birmingham City County
    Page 6 · response
    Published 14 August 2026

    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

    Continue reviewing training requirements and operator competency arrangements through continuous improvement and TSA accreditation processes.

    Verbatim wording from the response

    “3. Training requirements and operator competency arrangements will continue to be reviewed as part of the service's continuous improvement framework and TSA accreditation requirements.”

    Source location

    Response from Birmingham City County
    Page 7 · response
    Published 14 August 2026

    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 sprinkler notification transmitter was correctly configured and wired, so the signals were not sent in the wrong order because of installation error.

    Verbatim wording from the response

    “Post-incident investigations undertaken by servicing and maintenance contractors identified that the CHUBB Skyresponse platform transmitter had been correctly configured and wired correctly. There was not an error in installation configuration sending notifications the incorrect way around.”

    Source location

    Response from Birmingham City County
    Page 5 · response
    Published 14 August 2026

    Open published response

  2. Rutland and North Leicestershire

    AI-generated summary

    Richard Charles 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

    Richard Charles HUNT was a serving prisoner at HMP Stocken who set fire to his cell on 11 July 2025, was taken to hospital, and died later that day from smoke inhalation. The report raises concerns that the aspirating fire detection system’s buzzer failed to sound because it had been deliberately disabled or tampered with, and that similar issues were found across the prison estate without central oversight of faults.

    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 keep aspirating fire detection system fault buzzers operational

    Wider context from the report

    “On both occasions prior to setting fire to his cell, ████████ it is designed to trigger an alarm on a control panel which is housed in the Wing Office situated on each wing. The triggering of that alarm should not only display a light but also sound a buzzer to alert staff of a fault. On the 19th March when Mr Hunt set fire to his cell on K Wing and on 11th July when he set fire to his cell on I Wing this buzzer did not sound. On 19th March 2025, Mr Hunt himself raised the alarm by sounding his cell bell and was discovered. He required CPR and was hospitalised for 3 days. The aspirating fire alarm system did not sound an alarm in the K Wing office. On 11th July the detection of Mr Hunt having set fire to his cell was fortuitous as an OSG was conducting an ACCT check on another prisoner in a nearby cell and smelt smoke. The alarm indication of a fault had been triggered 2 hours before this discovery and Mr Hunt’s cell had been smouldering for around this period of time undetected. Again, no buzzer was sounded. Following the fire on the 19th March 2025, investigation revealed that the aspirating fire detection system buzzer with the Wing Office had been ‘disabled’ and it was believed to have been deliberately silenced for 12 months prior to the incident. Following the fire and Mr Hunt’s death on the 11th July 2025, the aspirating fire detection system was inspected and reviewed across the HMP Stocken Estate by ADT alarms, who are contracted to maintain the system. That inspection revealed that the reason the alarm on I wing, which was triggered but did not sound the buzzer, was because the control panel in the Wing Office (and in which the buzzer was housed) had been deliberately tampered with, by the insertion of a rubber glove between the connectors thereby disabling the buzzer. Further inspection of the aspirating fire detection system panels across the HMP Stocken Estate found for example the control panel on L Wing had been vandalised ████████ and that control panel units in other Wings including segregation had been deliberately forced open to gain access. I further understand that the aspirating fire detection system panels on the Wings do not link with the main Control Room, meaning there is no central oversight of faults (whether deliberate coverd or indicating a fire) for action to be immediately taken. Whilst HMP Stocken may have a system of maintenance of the aspirating fire detection system within the prison, that maintenance system is futile if staff are going to deliberately tamper with that system to disable the buzzer which is designed to alert them as to risk. This is not an isolated occurrence and is systemic across the HMP Stocken Estate. ”

    Source location

    Richard Charles HUNT · 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 protect aspirating fire detection system control panels from deliberate tampering

    Wider context from the report

    “On both occasions prior to setting fire to his cell, ████████ it is designed to trigger an alarm on a control panel which is housed in the Wing Office situated on each wing. The triggering of that alarm should not only display a light but also sound a buzzer to alert staff of a fault. On the 19th March when Mr Hunt set fire to his cell on K Wing and on 11th July when he set fire to his cell on I Wing this buzzer did not sound. On 19th March 2025, Mr Hunt himself raised the alarm by sounding his cell bell and was discovered. He required CPR and was hospitalised for 3 days. The aspirating fire alarm system did not sound an alarm in the K Wing office. On 11th July the detection of Mr Hunt having set fire to his cell was fortuitous as an OSG was conducting an ACCT check on another prisoner in a nearby cell and smelt smoke. The alarm indication of a fault had been triggered 2 hours before this discovery and Mr Hunt’s cell had been smouldering for around this period of time undetected. Again, no buzzer was sounded. Following the fire on the 19th March 2025, investigation revealed that the aspirating fire detection system buzzer with the Wing Office had been ‘disabled’ and it was believed to have been deliberately silenced for 12 months prior to the incident. Following the fire and Mr Hunt’s death on the 11th July 2025, the aspirating fire detection system was inspected and reviewed across the HMP Stocken Estate by ADT alarms, who are contracted to maintain the system. That inspection revealed that the reason the alarm on I wing, which was triggered but did not sound the buzzer, was because the control panel in the Wing Office (and in which the buzzer was housed) had been deliberately tampered with, by the insertion of a rubber glove between the connectors thereby disabling the buzzer. Further inspection of the aspirating fire detection system panels across the HMP Stocken Estate found for example the control panel on L Wing had been vandalised ████████ and that control panel units in other Wings including segregation had been deliberately forced open to gain access. I further understand that the aspirating fire detection system panels on the Wings do not link with the main Control Room, meaning there is no central oversight of faults (whether deliberate coverd or indicating a fire) for action to be immediately taken. Whilst HMP Stocken may have a system of maintenance of the aspirating fire detection system within the prison, that maintenance system is futile if staff are going to deliberately tamper with that system to disable the buzzer which is designed to alert them as to risk. This is not an isolated occurrence and is systemic across the HMP Stocken Estate. ”

    Source location

    Richard Charles HUNT · 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

    Lack of central oversight of aspirating fire detection system faults

    Wider context from the report

    “On both occasions prior to setting fire to his cell, ████████ it is designed to trigger an alarm on a control panel which is housed in the Wing Office situated on each wing. The triggering of that alarm should not only display a light but also sound a buzzer to alert staff of a fault. On the 19th March when Mr Hunt set fire to his cell on K Wing and on 11th July when he set fire to his cell on I Wing this buzzer did not sound. On 19th March 2025, Mr Hunt himself raised the alarm by sounding his cell bell and was discovered. He required CPR and was hospitalised for 3 days. The aspirating fire alarm system did not sound an alarm in the K Wing office. On 11th July the detection of Mr Hunt having set fire to his cell was fortuitous as an OSG was conducting an ACCT check on another prisoner in a nearby cell and smelt smoke. The alarm indication of a fault had been triggered 2 hours before this discovery and Mr Hunt’s cell had been smouldering for around this period of time undetected. Again, no buzzer was sounded. Following the fire on the 19th March 2025, investigation revealed that the aspirating fire detection system buzzer with the Wing Office had been ‘disabled’ and it was believed to have been deliberately silenced for 12 months prior to the incident. Following the fire and Mr Hunt’s death on the 11th July 2025, the aspirating fire detection system was inspected and reviewed across the HMP Stocken Estate by ADT alarms, who are contracted to maintain the system. That inspection revealed that the reason the alarm on I wing, which was triggered but did not sound the buzzer, was because the control panel in the Wing Office (and in which the buzzer was housed) had been deliberately tampered with, by the insertion of a rubber glove between the connectors thereby disabling the buzzer. Further inspection of the aspirating fire detection system panels across the HMP Stocken Estate found for example the control panel on L Wing had been vandalised ████████ and that control panel units in other Wings including segregation had been deliberately forced open to gain access. I further understand that the aspirating fire detection system panels on the Wings do not link with the main Control Room, meaning there is no central oversight of faults (whether deliberate coverd or indicating a fire) for action to be immediately taken. Whilst HMP Stocken may have a system of maintenance of the aspirating fire detection system within the prison, that maintenance system is futile if staff are going to deliberately tamper with that system to disable the buzzer which is designed to alert them as to risk. This is not an isolated occurrence and is systemic across the HMP Stocken Estate. ”

    Source location

    Richard Charles HUNT · 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

    Complete 19 of the 26 fire-safety actions identified in the strategic action plan.

    Verbatim wording from the response

    “identified 26 actions including high level requests for changes to fire safety and detection systems as well as tasks for immediate actions such as replacing sounders on the fire alarm panels. To date, 19 of these actions have been completed with most of the remaining actions awaiting approval of spending bids.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 9 October 2025

    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

    Install a replacement fire panel after discovering that the existing panel had been tampered with.

    Verbatim wording from the response

    “Following Mr Hunt’s death and the discovery that the fire panel located in the wing office had been tampered with, preventing the buzzer from sounding, immediate action was taken and a replacement fire panel installed. The prison’s Health and Safety team was further tasked with undertaking a review of the physical security of the fire alarm panels, which found that the panels could be accessed, posing a significant risk to operational safety. Work is ongoing to rectify this issue, with access to fire alarm panel keys to be restricted to authorised personnel only - namely ADT (the fire alarm installer and maintainer), Amey, and Health & Safety advisors, preventing further unauthorised access and ensuring compliance with safety protocols.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 9 October 2025

    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

    Issue a national instruction requiring prison maintenance teams to keep fire-safety equipment efficient and fully operational.

    Verbatim wording from the response

    “Nationally, in response to the March incident, on 3 April 2025 a Service Managers Instruction (SMI) was issued to all prison maintenance teams, reiterating their responsibility to ensure that all fire safety equipment is maintained in an efficient and fully operational condition. Data from responses to this instruction is being used to provide assurance that panels’ fault alerts are un silenced, and that action is being taken to rectify any remaining issues.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 9 October 2025

    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 maintenance-response data to assure that fire-panel fault alerts are unsilenced and remaining issues are rectified.

    Verbatim wording from the response

    “Nationally, in response to the March incident, on 3 April 2025 a Service Managers Instruction (SMI) was issued to all prison maintenance teams, reiterating their responsibility to ensure that all fire safety equipment is maintained in an efficient and fully operational condition. Data from responses to this instruction is being used to provide assurance that panels’ fault alerts are un silenced, and that action is being taken to rectify any remaining issues.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 9 October 2025

    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

    Introduce a daily morning-meeting feedback system for discussing and reporting fire faults and tracking follow-up.

    Verbatim wording from the response

    “Locally, the Governor has introduced a daily feedback system into the morning meeting he chairs whereby all fire faults are discussed and reported. There is a specific focus on any alarms which are not sounding when in fault, and alarms which are continually sounding. This is to ensure that follow-up actions are completed where appropriate by prison staff and also that the maintenance provider is made aware of faults which require attention.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 9 October 2025

    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 post-fire visits and inspections to identify fire safety and management failures at HMP Stocken.

    Verbatim wording from the response

    “• Carry out an initial post fire visit to quickly gather vital information to establish and understand the facts of the fire event that occurred on 11th July 2025 in preparation for a post fire inspection.”

    Source location

    Response from The Crown Premises Fire & Safety Inspectorate
    Page 4 · response
    Published 9 October 2025

    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

    Serve enforcement action-plan notices on responsible duty holders addressing fire alarm faults, detector tampering, training, drills, maintenance, monitoring and spare components.

    Verbatim wording from the response

    “Following the post fire inspection on 16th July 2025, CPFSI took enforcement action by serving 28-day action plan notices to each of the Governing Governor, MOJ Property Service, Amey FM and HMPPS Director General Operations.”

    Source location

    Response from The Crown Premises Fire & Safety Inspectorate
    Page 6 · response
    Published 9 October 2025

    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

    Monitor compliance with served notices and conduct a follow-up visit to HMP Stocken in January 2026.

    Verbatim wording from the response

    “CPFSI continues to monitor progress with the actions being taken to comply with each Notice served and intends to conduct a follow up visit to HMP Stocken during January 2026.”

    Source location

    Response from The Crown Premises Fire & Safety Inspectorate
    Page 6 · response
    Published 9 October 2025

    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

    Create and use a revised inspection aide memoire specifying detailed checks of fire detection, warning, maintenance and anti-tampering arrangements in prison residential wings.

    Verbatim wording from the response

    “CPFSI has reviewed its business processes for inspecting residential wings in prisons. Specifically, by creating a revised aide memoire which provides inspectors with specific, detailed lines of enquiry to confirm that fire detection and warning systems can always provide effective detection performance. This is supported by: the provision of systems and components that are in accordance with the recommendations of relevant British Standards and expectations of MOJs own Technical Specifications; robust day-to-day management systems to deter tampering with life safety equipment and monitoring arrangements which ensure that specialist planned maintenance and remedial works are completed in a competent and timely fashion.”

    Source location

    Response from The Crown Premises Fire & Safety Inspectorate
    Page 16 · response
    Published 9 October 2025

    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

    Restrict access to fire-alarm-panel keys to authorised maintenance and health-and-safety personnel.

    Verbatim wording from the response

    “Following Mr Hunt’s death and the discovery that the fire panel located in the wing office had been tampered with, preventing the buzzer from sounding, immediate action was taken and a replacement fire panel installed. The prison’s Health and Safety team was further tasked with undertaking a review of the physical security of the fire alarm panels, which found that the panels could be accessed, posing a significant risk to operational safety. Work is ongoing to rectify this issue, with access to fire alarm panel keys to be restricted to authorised personnel only - namely ADT (the fire alarm installer and maintainer), Amey, and Health & Safety advisors, preventing further unauthorised access and ensuring compliance with safety protocols.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 9 October 2025

    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

    Commission fact-finding investigations into possible staff involvement in fire-equipment tampering.

    Verbatim wording from the response

    “Following the concerns regarding the tampering of fire alarm control panels the Governor of HMP Stocken commissioned two fact-finding investigations to determine if staff may have been involved with the tampering of fire safety equipment, and if so whether those staff could be identified. While it has not been possible to identify any individuals, the Governor has made clear to staff the seriousness of such action, and that anyone engaging in any tampering of the fire alarm system will be subject to formal disciplinary action.”

    Source location

    Response from HM Prison and Probation Service
    Page 3 · response
    Published 9 October 2025

    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

    Mandate that tampering with fire equipment is a disciplinary offence and will be investigated.

    Verbatim wording from the response

    “On 15 August 2025 a Governor’s Order was issued mandating that tampering with fire equipment is a disciplinary offence and will be investigated. This has been reiterated at a face to face, full staff meeting on 24th September 2025, in weekly blogs and in briefings to staff issued in April, July and August 2025. These set out clearly staff’s personal responsibility for fire safety, reminding staff of the need to ensure they understand the equipment in place and to report all faults and issues immediately, signposting how this is done and where support can be sought from. The Governor has also met with and written to the senior team outlining their responsibilities within their functions with regards to fire safety.”

    Source location

    Response from HM Prison and Probation Service
    Page 3 · response
    Published 9 October 2025

    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 staff fire-safety responsibilities, reporting requirements and disciplinary consequences through meetings, blogs, briefings and senior-team correspondence.

    Verbatim wording from the response

    “Following the concerns regarding the tampering of fire alarm control panels the Governor of HMP Stocken commissioned two fact-finding investigations to determine if staff may have been involved with the tampering of fire safety equipment, and if so whether those staff could be identified. While it has not been possible to identify any individuals, the Governor has made clear to staff the seriousness of such action, and that anyone engaging in any tampering of the fire alarm system will be subject to formal disciplinary action.”

    Source location

    Response from HM Prison and Probation Service
    Page 3 · response
    Published 9 October 2025

    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

    Replace fire-alarm systems on I and K wings and the Care and Separation Unit, with networking to the Control Room.

    Verbatim wording from the response

    “In regards to your concern regarding the link between the fault panels on the wings and the main Control Room, in November 2025 Ministry of Justice Property Directorate issued a mandate for the full replacement of the fire alarm systems on I and K wings and the Care and Separation Unit, with full networking back to the Control Room master fire alarm panel to allow any alarms or faults raised by the local fire alarm control panels on those wings to be visible in the Control Room. This is currently in the design and tendering stage with the intention that it will be rolled out as soon as practicable.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 9 October 2025

    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

    Crown bodies cannot be prosecuted under the Fire Safety Order, although enforcement notices remain available where continued non-compliance creates significant safety risks.

    Verbatim wording from the response

    “Crown bodies must comply with the provisions of the Order**, but they cannot be subject to prosecution**. Non-Crown Responsible Persons and others with duties under the Order in Crown premises can be prosecuted.”

    Source location

    Response from The Crown Premises Fire & Safety Inspectorate
    Page 16 · response
    Published 9 October 2025

    Open published response

  3. Inner North London

    AI-generated summary

    PAULINE VIOLET OAKLEY · 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

    Pauline Oakley fell onto an electric heater at her home on 3 April 2020, causing a fire. She sustained burns covering 60% of her body and died later that day in hospital. The concerns included the absence of assessments of the safety and suitability of her home and appliances, and the apparent lack of monitoring of the building’s fire alarm.

    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 provide monitoring of the fire alarm in the flats

    Wider context from the report

    “(3) The fire alarm in the flats was apparently not monitored by East End Homes, the police or the London Fire Brigade. When an alarm was activated it was dependent upon a resident in the flats or a member of the public to call the emergency services. Residents in the flats may have thought that the alarm was monitored and therefore there was no need for any resident to call the emergency services. ”

    Source location

    PAULINE VIOLET OAKLEY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. London (East)

    AI-generated summary

    Ms Mihaela Lazar and Ms Dorina Zangari · 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

    Ms Mihaela Lazar and Ms Dorina Zangari died after a fire at their home on 25 January 2017, probably started by clothing overlying a heater, and they were overcome by fire fumes before escaping. Concerns included inadequate fire detection and warning, the lack of a protected means of escape from the upper floor, and missing fire safety measures such as a kitchen door.

    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

    Absence of functioning fire detection and warning in maisonette halls or landings

    Wider context from the report

    “1. The maisonette in which Dorina Zangari and Michaela Lazar lived was let for use as a single private dwelling. As it happened, it was being used as a House in Multiple Occupation, but the fire safety issues of concern to LFB relate to any maisonette used as a single family dwelling. The lack of early detection and warning of fire (i.e. the provision of smoke alarms) and a protected means of escape from the upper floor of the maisonette (which was at too high a level for escape by windows) contributed to the occupants being unable to escape from the fire. The problem is threefold:- i) Undermining of the originally provided fire safety measures i.e. missing kitchen door ii) Absence of functioning fire detection and warning in the hall or landing, which was not required at the time of construction of the block of flats but, at the time of the fire, was a statutory requirement both for flats in single family occupation and multiple occupation; and iii) The design of the alternative means of escape, which comprised the balcony on the upper level of the maisonette, shared with the next door maisonette. This was acceptable at the time of construction but this is not acceptable today (without additional measures such as smoke alarms in every room) as this will involve breaking in to a neighbours flat. There are many thousands of these types of maisonette across the country which have not been upgraded using options in line with best practice guidance (see below) and this is leaving people at a significant risk of death or injury from fire. ”

    Source location

    Ms Mihaela Lazar and Ms Dorina Zangari · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. 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

    Failure to escalate fire-alarm activations to the fire brigade within 30 seconds

    Wider context from the report

    “7. That telecare system operators and WWA in particular, apply the British Standards Institute requirement to call for the help of the fire brigade after 30 seconds maximum of trying to contact a client if the client’s fire alarm goes off. ”

    Source location

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

    Open source report

  6. 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

    Failure of smoke detectors to alert a fire station

    Wider context from the report

    “(3) Mr Brincombe had received advice and had three smoke detectors fitted, however these would only alert Mr Brincombe to the fire. The smoke detectors would not alert a fire station, and in Mr Brincombe’s level of disability he would be unable to take evasive action. ”

    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

    Inform DCC care management staff about incident learning and remind them to consider alternative alerting options in similar circumstances.

    Verbatim wording from the response

    “a) All DCC care management staff to be informed of the learning from this incident and reminded of the need to consider alternative alerting options in any similar circumstances. Next monthly DCC staff newsletter due mid 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

    Inform NHS and DCC staff using the community equipment service about incident learning and available assistive-technology alerting solutions.

    Verbatim wording from the response

    “b) The new NHS and DCC community equipment service contract has assistive technology solutions available for alerting in these situations. We will ensure that all 2000 plus NHS and DCC staff who access this service are informed of the learning from this incident and directed to the solutions available within the service. Community equipment service Prescriber Newsletter and Newsflash to be issued by 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

    Raise incident learning and alternative alerting options through local and countywide management forums.

    Verbatim wording from the response

    “c) Learning from this incident to be raised via local and countywide management fora, to include reminders regarding options for alerting. 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

    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 position was interpreted

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

    PFD Monitor interpretation

    The Fire Service does not have facilities to monitor individual properties or respond directly to smoke-detector alerts.

    Verbatim wording from the response

    “Confirm whether in future, where a vulnerable adult is at high risk of accidental starting a fire, putting himself and others lives in danger, and being unable to take any action if this occurs, that smoke detectors would be fitted that have a direct link to a fire station.”

    Source location

    Kenneth-BRINICOMBE-Response
    Page 3 · response
    Published 25 August 2018

    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 most suitable fire-risk technology must be agreed with social services, the individual and other relevant parties.

    Verbatim wording from the response

    “3. Confirm whether in future, where a vulnerable adult is at high risk of accidental starting a fire, putting himself and others lives in danger, and being unable to take any action if this occurs, that smoke detectors would be fitted that have a direct link to a fire station.”

    Source location

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

    Open published response

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

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Data last updated 7 September 2026