Recurring concern

Unsafe emergency egress arrangements

First to latest report 21 Nov 2016 — 13 Jan 2025

Reports that mention this concern
5
Times this concern has been raised
6
Stated actions linked to this concern
9

What this concern includes

Includes failures of dedicated emergency-egress arrangements, including emergency exit doors, emergency-release window controls and checks that occupied premises retain usable alternative escape routes, where the deficiency can delay or prevent safe evacuation.

What is not included
  • Excludes ordinary access-control or security failures where emergency evacuation or egress is not materially involved.
  • Excludes general building, fire-safety or maintenance deficiencies that do not directly impair an emergency egress route or release arrangement.
  • Excludes outdoor water, river or vehicle egress hazards unless the assertion concerns emergency egress from a building or occupied premises.
  • Excludes generic emergency-response access failures concerning responders entering premises rather than occupants escaping.

Reports and published responses 5 reports

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

  1. Liverpool and the Wirral

    AI-generated summary

    Diane POOLE · 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 31 August 2024, Diane Poole left Victoria House Care Home through a faulty emergency escape door whose alarm did not sound, and staff were unaware she was missing for three hours. She was found after an unwitnessed fall, sustained head and facial fractures, and died on 23 September 2024; the fall and injuries contributed more than minimally to her death. The principal concerns were the defective emergency exit door and staff’s lack of awareness that she was missing.

    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

    Faulty emergency exit door

    Wider context from the report

    “The Court received evidence of the following: The investigation uncovered both the fault of the emergency exit door and a lack of awareness among the staff, highlighting the need for immediate corrective measures to prevent a recurrence of this incident. To address these issues, several actions will be implemented. Immediate corrective actions have been implemented to prevent a recurrence of this incident. Actions include: I Rigorous Alarm Checks: Regular inspections of all emergency exit alarms to ensure they are functioning correctly. I Increased Resident Headcounts: Staff will conduct hourly headcounts of all residents, with half-hour checks for those deemed high-risk. I Engaging Activities for High-Risk Residents: Structured, stimulating activities will be introduced to engage high-risk residents and reduce behaviours that may lead to attempts to leave the facility. I Improved Shift Handover Procedures: Shift handovers will be more resident-focused, ensuring clear communication and continuity of care. I Ongoing Staff Training: Regular training sessions will be conducted to reinforce the importance of supervision, resident safety, and emergency procedures. The Court seeks clarification that these actions have been implemented and are continuing ”

    Source location

    Diane POOLE · 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

    Close the front lounge area containing the escape door to residents and repurpose it as a meeting and family room.

    Verbatim wording from the response

    “Closure of the front lounge area where the escape door is situated | Area closed off following the incident | Management | | 31.08.24 | The lounge area was immediately closed off and is now closed to residents (now being used a meeting room – family room).”

    Source location

    Response from Victoria Residential Home
    Page 3 · response
    Published 15 January 2025

    Open published response

  2. Manchester South

    AI-generated summary

    Barry Martin · 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

    Barry Martin had a history of self-neglect, depression and heavy alcohol consumption, and was found deceased on 24 December 2020 after police had boarded up the front door of his property. His death was attributed to acute heart failure associated with acute pneumonia, bronchitis, coronary artery disease and physical frailty, with self-neglect contributing. The principal concern was that occupied houses boarded up by police should be checked to ensure residents have other safe exit routes.

    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 check for alternative safe exit routes when boarding up occupied houses

    Wider context from the report

    “After concerns were raised for his welfare, Mr Martin’s front door to his house was boarded up following a forced entry by Greater Manchester Police on 10th December 2020. There were no other exit routes from the property as there was no key available to Mr Martin to be able to use the rear door being the only other door. I am concerned that if occupied houses have to be boarded up that proper checks are made that there are other alternative safe exit routes for residents. ”

    Source location

    Barry Martin · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 property had rear-door access and issued keys, with no evidence the tenant lacked a key or access when the front door was boarded.

    Verbatim wording from the response

    “However, when our technician attended on this occasion, he was approached by a neighbour who confirmed that the tenant had been taken to hospital so was not in occupation at the time of the board up. Our technician noted that the property had rear door access and was therefore satisfied that the tenant had alternative access to the property.”

    Source location

    Response from Jigsaw Homes Tameside
    Page 1 · response
    Published 17 September 2021

    Open published response

  3. West Yorkshire Eastern

    AI-generated summary

    Philip Noel Sheridan · 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

    Philip Noel Sheridan suffered smoke inhalation and subsequently died after a fire on 26 June 2019 in the cellar flat where he lived. The flat had no smoke detector, had a single exit door without a handle positioned next to the fire, and had not received relevant planning, building-regulation, or housing inspection approval. Concerns included potential fire hazards in other properties, the processing of Local Housing Allowance without establishing safety, and the absence of an ongoing requirement to check that smoke alarms remained effective.

    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

    Potential fire hazards in properties managed by the same property managers, including inadequate smoke detection equipment or emergency escape routes

    Wider context from the report

    “1) ████████ entered an Assured Shorthold Tenancy Agreement with the deceased on 14th August 2013. He was a person in control of the cellar flat within the meaning defined in the Housing Act 2004. He and/or ████████ were involved in the management of other properties in the Leeds area in the period 2013-2019. He or they should have been aware that the cellar flat did not have planning consent, Building Regulation Approval and had not been inspected by Leeds City Council Housing Officers. The evidence taken at the Inquest gave rise to a concern on the balance of probability that the hazards identified in the cellar flat may be replicated in other properties managed by them, particularly in relation to the provision of smoke detection equipment or emergency escape routes in the event of fire. ”

    Source location

    Philip Noel Sheridan · 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

    Consult on extending smoke and carbon-monoxide alarm requirements to social housing.

    Verbatim wording from the response

    “We are currently consulting on proposals to extend the Smoke and Carbon Monoxide Alarm (England) Regulations 2015. We are proposing to mandate smoke alarms in all socially rented homes. Social landlords would be obliged to provide a smoke alarm on each storey of the premises on which there is a room used wholly or partly as living accommodation. This would bring requirements in line with those for private landlords.”

    Source location

    2021-0016-Response-from-Ministry-of-Housing-Communities-Local-Government-Redacted
    Page 1 · response
    Published 27 January 2021

    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

    Analyse responses to the smoke and carbon-monoxide alarm regulations consultation.

    Verbatim wording from the response

    “We are also proposing to amend the legislation to create an obligation for social and private landlords to repair or replace smoke alarms, once informed that they are faulty. We are not proposing to require landlords to test smoke alarms throughout the life of a tenancy. The consultation ran for 8 weeks from 17 November 2020 and closed on 11 January 2021. We are currently analysing the responses and will publish our response in due course.”

    Source location

    2021-0016-Response-from-Ministry-of-Housing-Communities-Local-Government-Redacted
    Page 2 · response
    Published 27 January 2021

    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

    Publish the Government response to the smoke and carbon-monoxide alarm regulations consultation.

    Verbatim wording from the response

    “We are also proposing to amend the legislation to create an obligation for social and private landlords to repair or replace smoke alarms, once informed that they are faulty. We are not proposing to require landlords to test smoke alarms throughout the life of a tenancy. The consultation ran for 8 weeks from 17 November 2020 and closed on 11 January 2021. We are currently analysing the responses and will publish our response in due course.”

    Source location

    2021-0016-Response-from-Ministry-of-Housing-Communities-Local-Government-Redacted
    Page 2 · response
    Published 27 January 2021

    Open published response

  4. London (East)

    AI-generated summary

    Ms Mihaela Lazar and Ms Dorina Zangari · 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

    Ms Mihaela Lazar and Ms Dorina Zangari died after a fire at their home on 25 January 2017, probably started by clothing overlying a heater, and they were overcome by fire fumes before escaping. Concerns included inadequate fire detection and warning, the lack of a protected means of escape from the upper floor, and missing fire safety measures such as a kitchen door.

    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 upgrade existing maisonettes in line with fire safety best-practice guidance

    Wider context from the report

    “1. The maisonette in which Dorina Zangari and Michaela Lazar lived was let for use as a single private dwelling. As it happened, it was being used as a House in Multiple Occupation, but the fire safety issues of concern to LFB relate to any maisonette used as a single family dwelling. The lack of early detection and warning of fire (i.e. the provision of smoke alarms) and a protected means of escape from the upper floor of the maisonette (which was at too high a level for escape by windows) contributed to the occupants being unable to escape from the fire. The problem is threefold:- i) Undermining of the originally provided fire safety measures i.e. missing kitchen door ii) Absence of functioning fire detection and warning in the hall or landing, which was not required at the time of construction of the block of flats but, at the time of the fire, was a statutory requirement both for flats in single family occupation and multiple occupation; and iii) The design of the alternative means of escape, which comprised the balcony on the upper level of the maisonette, shared with the next door maisonette. This was acceptable at the time of construction but this is not acceptable today (without additional measures such as smoke alarms in every room) as this will involve breaking in to a neighbours flat. There are many thousands of these types of maisonette across the country which have not been upgraded using options in line with best practice guidance (see below) and this is leaving people at a significant risk of death or injury from fire. ”

    Source location

    Ms Mihaela Lazar and Ms Dorina Zangari · 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

    Inadequate design of alternative means of escape from upper floors of maisonettes

    Wider context from the report

    “1. The maisonette in which Dorina Zangari and Michaela Lazar lived was let for use as a single private dwelling. As it happened, it was being used as a House in Multiple Occupation, but the fire safety issues of concern to LFB relate to any maisonette used as a single family dwelling. The lack of early detection and warning of fire (i.e. the provision of smoke alarms) and a protected means of escape from the upper floor of the maisonette (which was at too high a level for escape by windows) contributed to the occupants being unable to escape from the fire. The problem is threefold:- i) Undermining of the originally provided fire safety measures i.e. missing kitchen door ii) Absence of functioning fire detection and warning in the hall or landing, which was not required at the time of construction of the block of flats but, at the time of the fire, was a statutory requirement both for flats in single family occupation and multiple occupation; and iii) The design of the alternative means of escape, which comprised the balcony on the upper level of the maisonette, shared with the next door maisonette. This was acceptable at the time of construction but this is not acceptable today (without additional measures such as smoke alarms in every room) as this will involve breaking in to a neighbours flat. There are many thousands of these types of maisonette across the country which have not been upgraded using options in line with best practice guidance (see below) and this is leaving people at a significant risk of death or injury from fire. ”

    Source location

    Ms Mihaela Lazar and Ms Dorina Zangari · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Cumbria

    AI-generated summary

    Frazer Lee George Livesey · 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

    Frazer Lee George Livesey died after petrol ignited while he was working on motorcycles in a friend's flat, trapping him inside. He was overcome by fumes, and the principal concern was that window restrictors could not be disabled from inside during an emergency, potentially preventing escape.

    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 of window stays to be disableable from inside in an emergency

    Wider context from the report

    “The concern is that the window stays could not be disabled from the inside in an emergency, it is possible the deceased could have survived and his friend suffered less serious injuries if they had been able to escape. ”

    Source location

    Frazer Lee George Livesey · 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

    Remove the cable restrictors from the Old Fire Station flat’s windows.

    Verbatim wording from the response

    “In this particular flat (Old Fire Station, ground floor), our proposal is as follows:”

    Source location

    2016-0418-Response-by-IMPACT
    Page 6 · response
    Published 19 February 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

    Specify emergency-overridable or absent window restrictors and emergency-exitable window designs in new and replacement housing, subject to building constraints.

    Verbatim wording from the response

    “New Development Properties | Controls | Action Newbuild schemes that have not yet reached Building | Building Regulation approval is in all cases required for the works, and therefore the windows installed would have to comply and be approved by Building Control (and also on new build the third party warranty provided, such as LABC, Premier Guarantee etc) also up to relatively recently the most schemes would be Govt funded and have to meet the “Housing Quality Standards”. All of these requirements put differing constraints on the exact nature of any windows and opening mechanisms. | Windows installed in schemes from now on (see definition) will normally be UPVC outward opening side hung casement window, with easy clean hinges (to enable the window to be cleaned from the inside) with lockable handle and a restrictor which can be easily overridden in an emergency.”

    Source location

    2016-0418-Response-by-IMPACT
    Page 6 · response
    Published 19 February 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

    Adapt or replace existing non-overridable window restrictors in schemes where windows are not being replaced.

    Verbatim wording from the response

    “From now on, in such schemes, where we are not replacing windows, existing windows with restrictors without an override will be adapted or replaced to achieve as near as possible the approach set out above”

    Source location

    2016-0418-Response-by-IMPACT
    Page 7 · response
    Published 19 February 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

    Survey staff-supported residential properties and phase removal or replacement of fixed restrictors with emergency-overridable restrictors according to risk, phasing and funding.

    Verbatim wording from the response

    “Existing Properties Properties | Action Residential properties with staff on site. Vulnerable tenants, different building | All properties to be surveyed by end March 2017 to identify styles of windows and window”

    Source location

    2016-0418-Response-by-IMPACT
    Page 7 · response
    Published 19 February 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

    Assess other general-needs properties through stock-condition, repair and maintenance processes and include restrictor changes in the rolling inspection programme.

    Verbatim wording from the response

    “All other general needs properties. 2,300 properties | To be assessed through general stock condition surveys, repairs or maintenance. As properties become vacant, i.e. [“Properties as they become void”] they will be treated as for “Refurbished or remodelled properties “above. We have a 5yr rolling programme of inspection of all properties and we will include the removal or replacement of restrictors in those properties as they come up for inspection.”

    Source location

    2016-0418-Response-by-IMPACT
    Page 8 · response
    Published 19 February 2017

    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

    Window changes cannot be applied universally because of safety risks, building design, regulatory restrictions, tenant vulnerability and potentially prohibitive replacement costs.

    Verbatim wording from the response

    “2. Not all properties can have their restrictors removed (eg on upper floors where the risk from a fall would be high or where Building Regulations do not allow it)”

    Source location

    2016-0418-Response-by-IMPACT
    Page 6 · response
    Published 19 February 2017

    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

    Window exit will remain restricted for upper-floor tenants with dementia or impaired judgement because jumping risks are too great.

    Verbatim wording from the response

    “2. We will continue to restrict ease of window exit for all properties with tenants in upper floor flats with dementia or otherwise impaired judgement, where the risk to them of trying to jump from a window would be too great”

    Source location

    2016-0418-Response-by-IMPACT
    Page 8 · response
    Published 19 February 2017

    Open published response

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