Recurring concern

Fire risk assessment processes failing to respond to material changes

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First reported 3 Jun 2014•Latest report 21 Jul 2017

Definition

What this concern includes

Includes failures of the fire risk assessment process concerning timely initiation, referral, review, updating or prioritisation after material changes such as changes of use, structural alterations or major changes in a person's circumstances.

Not included

  • Excludes generic risk-assessment failures not explicitly concerning fire risk assessment.
  • Excludes failures of unrelated fire-safety controls where no material change and reassessment issue is identified.
  • Excludes deficiencies limited to documentation, staffing or communication unless they directly prevent the fire risk assessment process from responding to a material change.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2014–2017

First to latest report issue date

Stated actions
4

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.

Arjo UK Limited1
Care Quality Commission1
Department of Health and Social Care1
Homecare Association Limited1
Locala Community Partnerships C.I.C.1
Medicines and Healthcare products Regulatory Agency1
Ministry of Defence1
NHS England1
Proprietary Association of Great Britain1
Thornton & Ross Limited1

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 Yorkshire (West)

    AI-generated summary

    Pauline Taylor · 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 Taylor, who was bedbound and living alone, died in her home after a fire developed around her bed on 30 May 2015. The report identified concerns about the fire risks of low-paraffin emollient creams, limited warnings and awareness of those risks, the contribution of the airflow mattress, and the absence of a further risk assessment after her circumstances changed.

    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 offer a further fire-risk-assessment referral or review after a major change in circumstances

    Wider context from the report

    “(9) A further fire risk assessment referral/review was not offered to Mrs Taylor by Locala following a major change in her circumstance (she had become bedbound in March 2017.) ”

    Source location

    Pauline Taylor · 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

    Complete further risk assessments when relevant patients experience changes in health, circumstances or environment.

    Verbatim wording from the response

    “The first two points on the action plan seek to address the issue you have raised concerning further risk assessment: the action Locala will seek to achieve is that further risk assessments will be completed on all patients who smoke and/or have emollients in use with or without air products, at any stage where there is a change in their physical, physiological or mental health condition or circumstances, and a change in their environment or as a result. In addition, a flowchart is being designed to enable staff to identify patients that are frail or living with changing circumstances and documentation and training is being worked up to implement this throughout the organisation.”

    Source location

    2017-0330-Response-by-Locala_Redacted
    Page 2 · response
    Published 21 July 2017

    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

    Design a frailty and changing-circumstances flowchart and develop documentation and training for organisation-wide implementation.

    Verbatim wording from the response

    “The first two points on the action plan seek to address the issue you have raised concerning further risk assessment: the action Locala will seek to achieve is that further risk assessments will be completed on all patients who smoke and/or have emollients in use with or without air products, at any stage where there is a change in their physical, physiological or mental health condition or circumstances, and a change in their environment or as a result. In addition, a flowchart is being designed to enable staff to identify patients that are frail or living with changing circumstances and documentation and training is being worked up to implement this throughout the organisation.”

    Source location

    2017-0330-Response-by-Locala_Redacted
    Page 2 · response
    Published 21 July 2017

    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

    Audit records for missed further risk assessments and manage findings through community nursing team leaders.

    Verbatim wording from the response

    “In relation to undertaking further risk assessments records are being audited to see that this happening, and situations are not being missed, and this is being managed through the community nursing team leaders group. They are responsible within their teams for ensuring staff understand the need for further risk assessment when circumstances change.”

    Source location

    2017-0330-Response-by-Locala_Redacted
    Page 3 · response
    Published 21 July 2017

    Open published response

  2. Wiltshire and Swindon

    AI-generated summary

    Private Robert WOOD and Private Dean 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

    Private Robert Wood and Private Dean Hutchinson died on 14 February 2011 from inhalation of products of combustion and severe burns. The report raised concerns about fire risk assessments, training on electrical appliance overloading, identification of sleeping in office accommodation, and the effectiveness of random overnight checks.

    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

    Fire Diary failing to prioritise fire risk assessment reviews before changes of use or structural alterations

    Wider context from the report

    “(1) In evidence from ████████ from the Defence Fire Risk Management Organisation, I looked at the modification to the Fire Diary on the subject of fire risk assessments. I have attached a copy of the relevant extract marked “B” and the relevant section is already highlighted. It talks of a review of the fire risk assessment where there has been or there is planned to be a change in use or structure alteration. In evidence a number of witnesses, in particular ████████ who carries out fire risk assessments, agreed that advice should be sought quickly before any change of use or structural alteration. I appreciate that there will be incidences whereby a change of use can take place extremely quickly however I considered that this section did not weight a preference in favour of a review prior to a change of use or any structural alteration taking place. It is my view that the current version gives equal weighting to the 2 options available when the evidence I heard was in favour of advice being sought before a change of use was carried out or any structural alteration taking place. In this particular case the alterations were phased alterations over a period of time and whilst I formed the view that it was speculative on the facts of this particular case that such a review before the change would have made a difference that cannot be said for future incidences. As the evidence I heard supports a preference for such reviews to be undertaken before a change of use or structural alteration takes place I would ask that this be reviewed insofar as the wording is concerned. ”

    Source location

    Private Robert WOOD and Private Dean HUTCHINSON · 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

    Amend the DFRMO Fire Diary to require competent fire-risk assessment advice before premises changes or when assessments may be invalid, and strengthen electrical-overloading guidance.

    Verbatim wording from the response

    “In response to your first two concerns, the Defence Fire Risk Management Organisation (DFRMO) Fire Diary has been amended to make it clear that the advice of a competent fire risk assessor must be sought before any changes take place within a premise or if there is a suspicion that the fire risk assessment is no longer valid; and to provide additional guidance and advice on the risks of electrical overloading including the need to contact a competent electrician if there are concerns. The revised Fire Diary is enclosed for your information. The Fire Non-Commissioned Officer (NCO) course content has also been amended and now allocates more time and emphasis on the fire risks associated with electrical overloading. A copy of the PowerPoint presentation delivered on this course is also enclosed for your information.”

    Source location

    2014-0556-Response
    Page 1 · response
    Published 3 June 2014

    Open published response
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Data last updated 7 September 2026