Recurring concern

Failure to reliably identify and refer vulnerable people at risk of fire

First to latest report 26 Sep 2013 — 3 Aug 2021

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
6

What this concern includes

Includes failures to identify vulnerable people or households at material risk of fire and to refer or share the relevant information with the Fire and Rescue Service for home fire-safety advice, assessment or assistance.

What is not included
  • Excludes general fire prevention, detection, evacuation, alarm, sprinkler and premises-design deficiencies where no failure to identify or refer vulnerable people is asserted.
  • Excludes generic information-sharing or safeguarding failures that are not specifically connected to identifying vulnerable people at risk of fire or referring them to the Fire and Rescue Service.
  • Excludes failures in carrying out or following up a home fire-safety assessment after a suitable referral has been made.
  • Excludes fire risks affecting premises or people without a vulnerable-person identification or Fire and Rescue Service referral component.

Reports and published responses 3 reports

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

  1. West Sussex

    AI-generated summary

    Pauline McInroy ALLISON · 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 McInroy Allison died at hospital on 26 March 2021 from significant burns sustained in a house fire after smoking materials came into contact with flammable materials on her bed. She was largely bedbound and unable to escape. The principal concerns were the fire risks associated with emollient creams, smoking in bed, and air mattresses, and whether patients, families and carers were sufficiently aware of these risks and referred for fire safety advice.

    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 refer patients using emollient creams to their local Fire & Rescue Service for advice and assistance

    Wider context from the report

    “(1) Mrs Allison used emollient creams containing flammable ingredients. I heard evidence that these ingredients can build up on clothing and bedding. The effect of this build up is to make material ignite more easily and burn more quickly. In addition to this the presence of an air mattress (often used by those with limited mobility) can further facilitate the ignition and spread of a fire by introducing additional air to the fire if it melts or punctures. The West Sussex Fire & Rescue Service informed me that they are trying to improve awareness amongst families, care providers and GPs of the increased risk of fire posed by the use of these types of emollient creams especially by immobile persons who smoke. I am concerned that not enough is being done to ensure that these patients, their families, and carers are aware of the risks and to ensure that they are referred to their local Fire & Rescue Service for advice and assistance. ”

    Source location

    Pauline McInroy ALLISON · 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

    Reissue primary-care warnings, reinforce patient and carer advice, distribute the patient leaflet through community pharmacies, and encourage fire-service referrals for at-risk patients.

    Verbatim wording from the response

    “month'. Anonymised reference to this incident will be made to emphasise it was a local case and primary care to be reminded to advise patients who use these products not to smoke or go near naked flames, and warn about the easy ignition of clothing, bedding, dressings, and other fabric that have dried residue of an emollient product on them . In addition, within the newsletter, primary care will be encouraged to ask any at risk patients (i.e. known smokers or those on home oxygen) to talk to their local Fire and Rescue Service and seek advice and guidance to help minimise the risk when using emollients.”

    Source location

    2021-0269-Response-from-CCGs
    Page 4 · response
    Published 12 August 2021

    Open published response

  2. Manchester City

    AI-generated summary

    Mr Brian MacLean · 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 Brian MacLean died on 19 March 2016 from smoke inhalation contributed to by alcohol toxicity after a fire started while he was smoking on his sofa. The report raised concerns about insufficiently proactive social services involvement, failure to identify and refer him as being at risk of fire, and the absence of automatic processes for fire-risk assessment, referrals, sprinklers and other preventive measures.

    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 refer people at risk of fire to GMFRS

    Wider context from the report

    “2. There was no identification of the deceased as being potentially at risk of a fire in his premises and no referral to GMFRS. ”

    Source location

    Mr Brian MacLean · 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

    Review contacts closed or classified as non-urgent by the two officers.

    Verbatim wording from the response

    “1. All contacts which have been closed or viewed as non-urgent by Officers A and B have been reviewed.”

    Source location

    2017-0233-Response-by-Manchester-City-Council
    Page 3 · response
    Published 24 September 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 20% of Contact Centre contacts classified as No Further Action between July and September 2017.

    Verbatim wording from the response

    “2. An audit of 20% of all contacts classed as “NFA” (No Further Action) by the Contact Centre between July 2017 and September 2017 is being undertaken”

    Source location

    2017-0233-Response-by-Manchester-City-Council
    Page 3 · response
    Published 24 September 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

    Undertake regular audits of Contact Centre work through the Quality Assurance Team.

    Verbatim wording from the response

    “4. The Quality Assurance Team are to undertake regular audits of the work undertaken by the Contact Centre.”

    Source location

    2017-0233-Response-by-Manchester-City-Council
    Page 3 · response
    Published 24 September 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

    Explore increasing social work supervision and oversight of Contact Centre officers.

    Verbatim wording from the response

    “5. MCC is currently exploring increasing social work supervision and oversight of the Contact Centre officers”

    Source location

    2017-0233-Response-by-Manchester-City-Council
    Page 3 · response
    Published 24 September 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

    Continue raising adult social care staff awareness of Greater Manchester Fire and Rescue Service offerings through partnership meetings and consideration of extended partnership working.

    Verbatim wording from the response

    “6. MCC has considered the recommendations of the GMFRS report and will continue with the work currently underway to raise the awareness of the services offered by GMFRS among adult social care staff. There are regular meeting between the Community Safety Officer from GMFRS and MCC to ensure that all options for extending partnership working are considered.”

    Source location

    2017-0233-Response-by-Manchester-City-Council
    Page 3 · response
    Published 24 September 2017

    Open published response

  3. Carmarthenshire and Pembrokeshire

    AI-generated summary

    Betty Grace Payne · 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

    Betty Grace Payne, aged 84, lived alone and was found dead after a house fire on 16 July 2013. The report identified concerns about the sharing of information about vulnerable people with the Fire Service and the availability of fire-safety checks and related training.

    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 share information about vulnerable people with the Fire Service

    Wider context from the report

    “(2) The improved sharing of information about vulnerable people with the Fire Service could identify those at risk. (3) It is acknowledged that the sharing of information of this kind may for legal reasons not always be possible. (4) Where this information cannot be disclosed then Local Authority staff could receive training from the Fire Service. This will enable Local Authority staff to undertake Home Fire Safety Checks and implement measures to reduce the risk of fire. This training is available from the Fire Service. ”

    Source location

    Betty Grace Payne · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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