Recurring concern

Unsafe operation of door-closing systems

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First reported 9 Apr 2014•Latest report 12 Dec 2016

Definition

What this concern includes

Includes failures of door-closing arrangements, including door-closer condition, closing force, closing speed, operation and environmental or design factors such as airflow, where these make doors unsafe or ineffective during closing.

Not included

  • Excludes general door, fire-door or access-control deficiencies where the unsafe condition is unrelated to door-closing operation.
  • Excludes failures concerning door opening, locking, access or emergency release unless they also directly concern unsafe closing behaviour.
  • Excludes generic maintenance, building-design or environmental deficiencies unless they directly cause or form part of an unsafe door-closing system.
Reports
4

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2014–2016

First to latest report issue date

Stated actions
2

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.

Borough Care Ltd1
Department of Health and Social Care1
London Borough of Camden1
Office of the Chief Coroner1
Recipient name withheld1
Tameside and Glossop Integrated Care NHS Foundation Trust1
The Stockton1

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. Inner North London

    AI-generated summary

    Ellen Eileen Margaret Kelly · 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

    Ellen Eileen Margaret Kelly suffered smoke inhalation injuries in a flat fire on 7 July 2016 after a cigarette was not fully extinguished, and died at St Marys Hospital, Paddington, on 16 July 2016. The substantive concerns were that the flat’s front door lacked a self-closing mechanism and that other doors in the block did not meet the 30-minute fire-resistance standard, potentially allowing fire and smoke to spread more quickly.

    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

    Lack of proper self-closing mechanisms on flat front doors

    Wider context from the report

    “Evidence was given by Watch Manager ████████ from the London Fire Brigade that: 1. ████████ is a block owned by London Borough of Camden. 2. At the time of the fire, the front door of Flat 13 was left open whilst the occupant went to raise the alarm. This caused the fire to spread more quickly than would have been the case had the door been shut. It also caused smoke to disperse in the common parts of the building. 3. Another family was trapped in Flat 15 (above Flat 13) until the London Fire Brigade attended. 4. The front door of Flat 13 should have been fitted with a self-closing mechanism but was not. 5. Other front doors in the block identified by the London Fire Brigade when they attended were not of a suitable standard in that they did not comply with the 30 minute fire resistant British Standard. I consider that it is likely that there are front doors of flats within Kilburn Gate which do not have: a. A proper self-closing mechanism in accordance with legal requirements as this was the case with the door to Flat 13, and b. Do not comply with the relevant British Standard, in that they are not fire resistant for 30 minutes or more. ”

    Source location

    Ellen Eileen Margaret Kelly · 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

    Install FD30S flat entrance doors with closers, renew communal intake doors and redecorate Kilburn Gate communal areas to Class 0 fire-resistant standard.

    Verbatim wording from the response

    “In regards to Kilburn Gate, fire safety works have been prioritised and have been tendered. This work includes installing new FD30s flat entrance doors incorporating door closers, renewal of communal intake doors and redecoration of communal areas to Class 0 fire resistant standard. We are currently consulting with Leaseholders in the block (as required by section 20 of the Landlord and Tenant Act 1985) and this consultation is due to be completed in mid-February and the works are expected to commence in March 2017.”

    Source location

    2016-0451-Response-by-London-Borough-of-Camden
    Page 1 · response
    Published 12 February 2017

    Open published response
  2. Manchester South

    AI-generated summary

    Hilda Haughton · 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

    Hilda Haughton was admitted to hospital with pneumonia and an acute exacerbation of COPD, and was injured when a fire door was electronically released during a power failure and struck her. The concerns included a subsequent fall from her bed when cot sides had not been raised, alleged lack of candour by hospital staff, and whether the response to the speed and power of electronically released fire doors was adequate.

    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 doors taking increased time to close

    Wider context from the report

    “2. The fire-doors are held open by electro-magnets. These are designed to be released remotely to contain any fire which may break out in the hospital. I was told that this type of door fastener is common to very many hospital wards around the U.K. The length of time it takes for the doors to close affects the speed and power with which they move. This time has been increased at Tameside hospital from 3 seconds to 6 seconds. Is this an adequate response and should this issue be raised with all hospitals having these door fasteners? (Secretary of State) ”

    Source location

    Hilda Haughton · 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

    Issue and publish an Estates and Facilities Safety Alert to NHS organisations covering self-closing fire doors and required risk-reduction actions.

    Verbatim wording from the response

    “Having considered the circumstances of this particular tragic incident and made reference to the British Standard, the Department has issued an Estates and Facilities Safety Alert to the NHS in England.”

    Source location

    2015-0460-Response-by-Department-of-Health
    Page 2 · response
    Published 29 October 2015

    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

    Controlling fire-door closing times in NHS premises is outside the Department’s power.

    Verbatim wording from the response

    “It is not therefore in the Department’s power to control how long it should take for fire doors to close in NHS premises. Such matters are for local management to decide in light of legislation, advice from relevant professional bodies and in line with recognised safety standards.”

    Source location

    2015-0460-Response-by-Department-of-Health
    Page 2 · response
    Published 29 October 2015

    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

    Local NHS management must decide fire-door closing times in light of legislation, professional advice and recognised safety standards.

    Verbatim wording from the response

    “It is not therefore in the Department’s power to control how long it should take for fire doors to close in NHS premises. Such matters are for local management to decide in light of legislation, advice from relevant professional bodies and in line with recognised safety standards.”

    Source location

    2015-0460-Response-by-Department-of-Health
    Page 2 · response
    Published 29 October 2015

    Open published response
  3. Teesside

    AI-generated summary

    Charles Ronald Hardiman · 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 26 February 2014, Charles Ronald Hardiman was pushed backwards by a back door moved suddenly by a gust of wind while he was at the top of steps at a public house. He fell down the stairs and sustained fatal head and chest injuries. The principal concern was that open front and back doors created a wind tunnel, causing the back door to move forcibly and suddenly.

    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

    Hazardous forceful and sudden movement of a back door caused by airflow between open doors

    Wider context from the report

    “(1) It was reported that the front door to the Public House was open and created a wind tunnel when the back door was open. This forced the back door to move forcibly and suddenly resulting in the accident. ”

    Source location

    Charles Ronald Hardiman · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  4. Manchester South

    AI-generated summary

    Doris 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

    Doris Taylor was admitted to a care home after reduced mobility and back pain, having been assessed as at high risk of falling. She suffered three falls, with the second apparently caused by a defective door-closer that knocked her over; the inquest concluded that her death was accidental and recorded pneumonia and multi-organ failure, with a fractured neck of femur among the underlying conditions. The principal concerns were inadequate staff understanding of reportable incidents and unsafe or excessively strong door-closers.

    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 maintain door-closers in safe working condition and with safe closing strength

    Wider context from the report

    “2. The door-closers on all doors in such an establishment should be in a safe working condition, and of such ‘strength’ as to be efficient in causing the door to close yet at the same time not so ‘strong’ as to make it dangerous as they close (as to knock over the person as happened to Mrs Taylor). ”

    Source location

    Doris Taylor · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026