Recurring concern

Failure to prevent unsafe access to elevated roofs

First to latest report 19 Sep 2014 — 22 Oct 2025

Reports that mention this concern: 2
Times this concern has been raised: 3
Stated actions linked to this concern: 5

What this concern includes

Includes failures of dedicated controls intended to prevent or restrict unsafe access to elevated roofs, including access barriers, protected fire escapes, railings, gates, locks, environmental risk assessments and remedial measures where these directly address roof-access risk.

What is not included

Excludes general roof maintenance, structural defects or building-survey failures where unsafe access to the roof is not the material concern.
Excludes ordinary access to roofs intended for authorised maintenance or emergency use when the access arrangement is appropriately controlled.
Excludes bridge, railway-track, balcony, tower, car-park and other elevated-location hazards unless the assertion specifically concerns access to an elevated roof.
Excludes general fall-prevention or premises-security deficiencies that are not directly linked to preventing unsafe access to an elevated roof.

Trends

Reports over time

Reports mentioning this concern, 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.

Birmingham and Solihull Integrated Care System1

Care Quality Commission1

Network Rail1

NHS England1

Recipient name withheld1

Reports and published responses 2 reports

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

22 Oct2025
Birmingham and Solihull
Concerns raised2
1. Unprotected fire escapes providing easy access to roofs in rehabilitation settings
2. Lack of environmental risk assessment of fire escape and roof accessibility
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Care Quality Commission
NHS Birmingham and Solihull Integrated Care Board
NHS Black Country Integrated Care Board
NHS England
Stated actions 5
1. NHS England
  Publish national best-practice guidance promoting person-centred safety assessment, formulation, management and environmental safety planning.
2. NHS England
  Liaise with Birmingham and Solihull Mental Health Foundation Trust about environmental risk assessment and unauthorised roof access from the fire escape.
3. NHS England
  Scope revisions to HTM 05-02 fire-safety guidance for healthcare-premises design.
1. NHS Birmingham and Solihull Integrated Care Board and NHS Black Country Integrated Care Board
  Escalate and monitor the development of national guidance on fire-escape protections in rehabilitation settings.
2. Care Quality Commission
  Request environmental risk assessments and observe ward environments during inspections to assess premises safety.
Respondent positions 4
1. NHS England
  Existing guidance and provider risk-assessment arrangements are considered appropriate to manage fire-escape and roof-access risks.
  Existing arrangements considered sufficient
1. Care Quality Commission
  Specific environmental risk assessments are not required; providers must instead take reasonable steps to manage health and safety risks.
  Disputes the concern
2. NHS England
  The Birmingham and Solihull Integrated Care Service is responsible for addressing the local fire-escape risk assessment in greater detail.
  Redirects responsibility
3. NHS England
  Further comment on the specific local risk assessment cannot be provided.
  Unable to act
AI-generated summary

Ricky James MONAHAN · 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

Ricky James MONAHAN, a resident of a rehabilitation unit detained under section 37 of the Mental Health Act, died after falling from a height on 18 March 2025. The report identified an unprotected fire escape accessible from the garden and roof, no environmental risk assessment of this access, reliance on individual risk assessments, and a lack of guidelines for protecting fire escapes in rehabilitation settings.

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
Unprotected fire escapes providing easy access to roofs in rehabilitation settings
Wider context from the report
“1. Mr Monahan was in a 10 bedded rehabilitation unit and was detained under S37 of the Mental Health Act. There was an unprotected fire escape at the rear of the building which could be easily accessed from the garden which in turn gave easy access to the roof. No environmental risk assessment had been completed regarding how accessible the fire escape was and how it easily provided access to the roof due to inadequate railings at the top of the staircase. The trust relied on individual risk assessments when considering what controls were required for individual patients when accessing the garden. 2. The inquest heard how there are no current guidelines setting out what protections are required for fire escapes in rehabilitation settings. The lack of any guidelines presents a risk of future deaths and in my view, action should be taken. ”
Source location
Ricky James MONAHAN · 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 environmental risk assessment of fire escape and roof accessibility
Wider context from the report
“1. Mr Monahan was in a 10 bedded rehabilitation unit and was detained under S37 of the Mental Health Act. There was an unprotected fire escape at the rear of the building which could be easily accessed from the garden which in turn gave easy access to the roof. No environmental risk assessment had been completed regarding how accessible the fire escape was and how it easily provided access to the roof due to inadequate railings at the top of the staircase. The trust relied on individual risk assessments when considering what controls were required for individual patients when accessing the garden. 2. The inquest heard how there are no current guidelines setting out what protections are required for fire escapes in rehabilitation settings. The lack of any guidelines presents a risk of future deaths and in my view, action should be taken. ”
Source location
Ricky James MONAHAN · 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
Publish national best-practice guidance promoting person-centred safety assessment, formulation, management and environmental safety planning.

Verbatim wording from the response
“NHS England also published the Staying Safe from Suicide: Best Practice Guidance for Safety Assessment, Formulation and Management on 4 April 2025. It promotes a shift towards a more holistic, person-centred approach rather than relying on risk prediction, which can be unreliable because suicidal thoughts can change quickly. Instead, it recommends using a method based on understanding each person’s situation and managing their safety. The purpose of this guidance is to enable mental health practitioners to adopt best practice principles in working with people of all ages to stay safe from suicide. The guidance highlights environmental safety as one of six steps of safety planning, which should include reducing access to or avoiding high risk locations.”

Source location
Response from NHS England
Page 2 · response
Published 23 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
Liaise with Birmingham and Solihull Mental Health Foundation Trust about environmental risk assessment and unauthorised roof access from the fire escape.

Verbatim wording from the response
“NHS England’s regional mental health team has liaised with the Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) regarding your concerns, including the lack of environmental risk assessment of the fire escape, and particularly its ability to allow unauthorised access to the roof.”

Source location
Response from NHS England
Page 2 · response
Published 23 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
Scope revisions to HTM 05-02 fire-safety guidance for healthcare-premises design.

Verbatim wording from the response
“NHS England’s Estates Team are currently scoping HTM 05-02, fire safety in the design of healthcare premises, which will be revised imminently.”

Source location
Response from NHS England
Page 3 · response
Published 23 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
Escalate and monitor the development of national guidance on fire-escape protections in rehabilitation settings.

Verbatim wording from the response
“The inquest also heard how there are no current guidelines setting out what protections are required for fire escapes in rehabilitation settings. The lack of any guidelines presents a risk of future deaths and therefore action should be taken.”

Source location
Response from Birmingham and Solihull NHS
Page 2 · response
Published 23 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
Request environmental risk assessments and observe ward environments during inspections to assess premises safety.

Verbatim wording from the response
“As part of our inspection process, CQC will routinely ask for the most recent environmental risk assessment to provide assurance that providers have made the premises safe for people who use the service. CQC inspectors will also observe the ward environment as part of an inspection. In our inspection in October 2023, CQC found that there were risk assessments in place in all ward areas which removed or reduced any risks they identified. The report in October 2023 does not make specific reference to the external fire escape.”

Source location
Response from Care Quality Commission
Page 2 · response
Published 23 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
Existing guidance and provider risk-assessment arrangements are considered appropriate to manage fire-escape and roof-access risks.

Verbatim wording from the response
“Whilst none of the documents mentioned above specifically refer to fire escapes, secure access to fire escapes should be embedded within the provider’s risk assessments. The clinical risk assessment should cover the patient’s current level of risk (absconding, self-harm etc) and the patient should be supervised according to the level of risk posed.”

Source location
Response from NHS England
Page 4 · response
Published 23 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
Specific environmental risk assessments are not required; providers must instead take reasonable steps to manage health and safety risks.

Verbatim wording from the response
“We do not specify that all providers must carry out specific environmental risk assessments, however providers must make sure that the premises and any equipment used is safe and where applicable, available in sufficient quantities. CQC understands that there may be inherent risks in carrying out care and treatment, and we will not consider it to be unsafe if providers can demonstrate that they have taken all reasonable steps to ensure the health and safety of people using their services and to manage risks that may arise during care and treatment.”

Source location
Response from Care Quality Commission
Page 2 · response
Published 23 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
The Birmingham and Solihull Integrated Care Service is responsible for addressing the local fire-escape risk assessment in greater detail.

Verbatim wording from the response
“I note that your Report is also addressed to the Birmingham and Solihull Integrated Care Service, who will be able to address the position locally in more detail.”

Source location
Response from NHS England
Page 2 · response
Published 23 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
Further comment on the specific local risk assessment cannot be provided.

Verbatim wording from the response
“Ultimately, there appears to be appropriate guidance in place to ensure that incidents such as this should not happen, however it appears that the local risk assessment did not take the specific risks of the fire escape and access to the roof into account. NHS England is not able to comment further on this and directs the Coroner to the Birmingham and Solihull Integrated Care Service in this regard.”

Source location
Response from NHS England
Page 4 · response
Published 23 October 2025
Open published response
19 Sep2014
Inner South London
Concerns raised1
1. Failure to block access to commercial-unit roofs under the railway arches
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Aaron Jacob Plowman · 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 14 March 2014, Aaron Jacob Plowman was found to have fallen through a damaged plastic roof over garage premises onto a concrete floor. The principal concerns were that access to the roofs of commercial units under the railway arches had not been blocked and that a specific access point from nearby shops remained viable.

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 block access to commercial-unit roofs under the railway arches
Wider context from the report
“(1) Access to the roofs of the commercial units under the railway arches has not been blocked off from persons gaining access by climbing up from the street. (2) Specifically the access point from the Lycamobile kiosk and Sonny Kebab and Chicken shop on the New Kent Road under the railway arches remains viable. ”
Source location
Aaron Jacob Plowman · Prevention of Future Deaths report
Page 1 · concerns
Open source report