Recurring concern

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

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First reported 26 Sep 2013•Latest report 3 Aug 2021

Definition

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.

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: 3
Individual concerns: 3
Date range: 2013–2021
Stated actions: 6

Reports 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.

British Medical Association1

Carmarthenshire County Council1

Great Places Housing Association1

Manchester City Council1

NHS Greater Manchester Integrated Care Board1

NHS Surrey and Sussex Integrated Care Board1

Pembrokeshire County Council1

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.

3 Aug2021
West Sussex
Concerns raised1
1. Failure to refer patients using emollient creams to their local Fire & Rescue Service for advice and assistance
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  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.
  Stated by NHS Brighton & Hove CCG and NHS East Sussex CCG and NHS West Sussex CCGStated planned
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
11 Sep2017
Manchester City
Concerns raised1
1. Failure to refer people at risk of fire to GMFRS
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Review contacts closed or classified as non-urgent by the two officers.
  Stated by Manchester City CouncilStated completed
2. Action
  Audit 20% of Contact Centre contacts classified as No Further Action between July and September 2017.
  Stated by Manchester City CouncilStated in progress
3. Action
  Undertake regular audits of Contact Centre work through the Quality Assurance Team.
  Stated by Manchester City CouncilStated planned
1. Action
  Explore increasing social work supervision and oversight of Contact Centre officers.
  Stated by Manchester City CouncilStated in progress
2. Action
  Continue raising adult social care staff awareness of Greater Manchester Fire and Rescue Service offerings through partnership meetings and consideration of extended partnership working.
  Stated by Manchester City CouncilStated in progress
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
26 Sep2013
Carmarthenshire and Pembrokeshire
Concerns raised1
1. Failure to share information about vulnerable people with the Fire Service
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

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

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to refer people at risk of fire to GMFRS

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised1

Failure to share information about vulnerable people with the Fire Service

Actions described in response 1

Actions described in response 5