Recurring concern

Failure of external safety inspections to identify physical safety deficiencies

First to latest report 4 Oct 2013 — 14 May 2024

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

What this concern includes

Includes failures of external or regulatory safety inspections to identify, recognise or flag physical safety deficiencies in premises or equipment, including failures arising from inadequate inspection scope, preparation, scrutiny or follow-up.

What is not included
  • Excludes failures of internal maintenance, repair or remedial action where the inspection itself identified the deficiency.
  • Excludes generic audit, governance, staffing or training failures not directly tied to the effectiveness of an external safety inspection.
  • Excludes clinical, safeguarding or other process assessments unless the reported unsafe condition is failure of an external inspection to identify a physical safety deficiency.
  • Excludes factual hazards or unsafe physical conditions where no inspection failure is identified.

Reports and published responses 5 reports

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

  1. Surrey

    AI-generated summary

    Charlie Hopkins and William Robinson · 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

    Charlie Hopkins, aged 18, died at the scene of a road traffic collision on 26 September 2021, while William Robinson, aged 17, died in hospital on 4 December 2021 from injuries sustained in the same collision. The court found that excessive speed and alcohol contributed to the collision. Concerns were raised about risks involving young, new drivers and passengers, and about airbag faults not being identified during MOTs and vehicle servicing because of gaps in testing and diagnostic practices.

    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 MOT checks that airbag warning lights are functioning

    Wider context from the report

    “It is deeply concerning that such a significant safety fault with the VW Polo was not identified during the course of any of the annual MOTs it underwent from 14 March 2014 onwards. The court heard that the MOT manual itself does not require MOT testers to: (i) Check whether airbag warning lights are actually working. The court heard that it is quick and simple to check that a car’s airbag warning light is working. It is done by checking that the light illuminates briefly when the engine is switched on. Further the court heard that the MOT manual requires MOT testers to check that the anti-lock braking system (ABS) warning light is working in this manner. (ii) Carry out a diagnostic check of the car’s electrical systems to check whether there are any faults with the airbag module. The court heard that MOT testers rely on the illuminated warning light to assess whether there are any faults with the car’s airbag module. However, this will not identify a fault if the airbag warning light has been concealed. The court heard that there are universal diagnostic tools which can diagnose electrical faults, including airbag module faults, on any type of car, regardless of the manufacturer. The Coroner considers that there is a gap in the MOT manual which presents a risk of future deaths and you are invited to consider whether any amendments ought to be introduced to the MOT Manual to mitigate against that risk. ”

    Source location

    Charlie Hopkins and William Robinson · Prevention of Future Deaths report
    Page 5 · 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

    Assess MOT consultation results and consider additional measures, including visual inspection of the airbag fault light.

    Verbatim wording from the response

    “The Department and the Driver and Vehicle Standards Agency launched a consultation on updating the MOT to include new technology last year. We are currently considering the results of that consultation and what additional measures could be introduced. We will consider including a visual inspection of the functioning of the airbag fault light when the vehicle is turned on in those measures. Such a consideration will have to take into account whether it can be consistently applied, the amount of time that would be added to the test, and whether changes to the law are required; further exploration of this is needed.”

    Source location

    Department for Transport
    Page 2 · response
    Published 15 May 2024

    Open published response

  2. South London

    AI-generated summary

    Stephen Martin Verrall · 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

    Stephen Martin Verrall fell from the window of his first-floor room at St John’s Nursing Home and died from his injuries two days later. Concerns included an inadequate window restrictor, lack of a window-maintenance risk assessment, unrestricted windows remaining years later, and risks of residents leaving the home unaccompanied.

    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 routinely check window restrictors during regulatory inspections

    Wider context from the report

    “(1) Care Quality Commission – I was informed that CQC did not routinely check window restrictors on inspections. I was told that it was the responsibility of providers to comply with regulatory requirements in this regard. Whilst that is uncontroversial, the death in this case, and the fact that there remained unrestricted windows in August 2021 nearly four years after this death, demonstrated that checks by the regulator are required. Responsive checks after incidents are not sufficient to prevent deaths. ”

    Source location

    Stephen Martin Verrall · 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

    Conduct a targeted inspection of St John’s Nursing Home and follow up the Warning Notice to assess window safety and compliance.

    Verbatim wording from the response

    “Following the inquest we carried out a responsive “targeted” inspection of St John’s Nursing Home. “Targeted” inspections do not change the rating from the previous inspection but allow us to identify areas requiring action from the provider. This is because they do not assess all areas of a key question.”

    Source location

    2021-0336-Response-from-Care-Quality-Commission_Published
    Page 1 · response
    Published 14 October 2021

    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

    Providers remain responsible for ensuring adequate window restrictors and checking their robustness and compliance with relevant guidance.

    Verbatim wording from the response

    ““During our inspections, inspectors do not routinely check window restrictors as part of an inspection. However, inspectors may check some restrictors where observations on the day or information we receive prior to inspection identifies concerns. However, inspectors will check the systems and processes are in place to enable the provider to assess and monitor the quality of services and to identify, assess and manage risks to ensure people are protected against the risks of receiving inappropriate or unsafe care or treatment. It is care providers responsibility to ensure there are adequate window restrictors in place. It is also the provider’s responsibility to carry out adequate checks on the window restrictors to confirm that they are sufficiently robust and complied with the relevant guidance.””

    Source location

    2021-0336-Response-from-Care-Quality-Commission_Published
    Page 2 · response
    Published 14 October 2021

    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

    CQC will not introduce routine window-restrictor checks because provider risk management remains within its existing assessment framework.

    Verbatim wording from the response

    “Following the hearing we have met with the CQC Policy team to discuss your specific concerns and how they relate to the regulatory requirements, in particular, Regulation 12, Safe Care and Treatment | Care Quality Commission (cqc.org.uk), Regulation 15, Premises and equipment Regulation 15: Premises and equipment | Care Quality Commission (cqc.org.uk) and Regulation 17, Good governance Regulation 17: Good governance | Care Quality Commission (cqc.org.uk).”

    Source location

    2021-0336-Response-from-Care-Quality-Commission_Published
    Page 3 · response
    Published 14 October 2021

    Open published response

  3. Manchester South

    AI-generated summary

    Kenneth Roy Bardsley · 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

    Kenneth Roy Bardsley died at Salford Royal Hospital on 30 January 2017 from multiple injuries sustained as a passenger in a lift that malfunctioned at Serendipity Care Home. The inquest concluded that his accidental death was contributed to by failure of the lift’s interior door mechanism. Concerns included gaps in lift-engineer qualification requirements, failures to read and act on regulatory examination findings, unclear communication and follow-up processes, and insufficient systems for lift servicing and examination records.

    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 home inspections to identify unacted-on regulatory lift examination faults

    Wider context from the report

    “4. In inspections of the home, the CQC did not pick up that there were faults identified in the regulatory examination that had not been acted upon; ”

    Source location

    Kenneth Roy Bardsley · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Manchester South

    AI-generated summary

    Donald Berry · 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

    Donald Berry suffered severe injuries after being electrocuted while working at the Kendal Calling Festival on 22 July 2010, and died from ongoing health complications on 23 August 2016. The inquest heard concerns that a clearly visible high-voltage power line over the site had not been identified or addressed, despite an Event Safety Plan and the licensing process. It also heard that the issue had not been noted by any of the authorities involved and that site-visit arrangements were not replicated nationally.

    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 nationally replicated site visits for large events

    Wider context from the report

    “1. The inquest heard that the organisers of the event Kendal Calling had not identified that a clearly visible high voltage power line was running over the site and no steps had been taken to minimise the risk although an Event Safety Plan had been submitted to the licensing authority. 2. the inquest heard that the lack of identification of such a significant risk and need to take steps had been missed despite all the steps required by law to licensing such an event had taken place and an indication that the guidance in the Purple Book had been adhered to by the organisers . None of the authorities involved had noted the issue. Eden District Council (EDC)had now taken steps to do site visits for similar events within their area but this was not replicated nationally and was only done within EDC’s area for large events such as this. ”

    Source location

    Donald Berry · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Leicester City and South Leicestershire

    AI-generated summary

    Walter Gordon Powley · 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

    Walter Gordon Powley died after falling against uncovered radiator pipes and valves at a care and nursing home, sustaining burns to his legs. The report raised concerns about the high temperature of uncovered pipework, the absence of risk assessment of the room’s physical circumstances, and inspection bodies not identifying these issues. The inquest also identified inadequate ongoing risk assessments and failures to adhere to procedures for giving and recording medication as contributing factors.

    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 regular external inspections to recognize relevant physical safety matters

    Wider context from the report

    “3.Western Park View had been inspected by the Care Quality Commission and the Local Authority on a regular basis. Evidence indicated that these matters referred to had not been recognized by those bodies. ”

    Source location

    Walter Gordon Powley · 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

    Review the way adult social care inspections are conducted.

    Verbatim wording from the response

    “Our local compliance inspector did inspect the location in May 2012 and reviewed seven outcomes or regulations. Unfortunately they did not inspect against Regulation 15, Outcome 10. We are currently reviewing the way in which we inspect in adult social care and are piloting a new methodology very soon. Instead of the current outcomes we will be assessing against five domains and ask five questions:”

    Source location

    2013-0251-Response-by-Care-Quality-Commission
    Page 2 · response
    Published 4 October 2013

    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

    Pilot a new adult social care inspection methodology using five assessment domains.

    Verbatim wording from the response

    “Our local compliance inspector did inspect the location in May 2012 and reviewed seven outcomes or regulations. Unfortunately they did not inspect against Regulation 15, Outcome 10. We are currently reviewing the way in which we inspect in adult social care and are piloting a new methodology very soon. Instead of the current outcomes we will be assessing against five domains and ask five questions:”

    Source location

    2013-0251-Response-by-Care-Quality-Commission
    Page 2 · response
    Published 4 October 2013

    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 how the new inspection methodology can ensure inspectors check high-risk areas.

    Verbatim wording from the response

    “I welcome the timeliness of your report and will share its findings within my organisation; there are definitely lessons to be learnt from this very sad situation, which includes exploring the ways in which we can work more closely with the HSE and how we can ensure, within our new methodology, that our inspectors are checking high-risk areas such as this.”

    Source location

    2013-0251-Response-by-Care-Quality-Commission
    Page 2 · response
    Published 4 October 2013

    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

    Share the concerns and response with local-authority health and safety regulators through the Local Authority Unit.

    Verbatim wording from the response

    “HSE does not routinely inspect health and social care providers but does investigate serious incidents meeting our selection criteria and inspect where there is evidence of poor compliance. This may include, for example, where there is evidence of established standards, such as those covering prevention of burns, not being followed. This is also the case for non-nursing residential care which is enforced by local authorities. I will share this letter with local authority health and safety regulators via HSE’s Local Authority Unit and also arrange for the matter to be discussed at the next meeting of the national local authority practitioner forum.”

    Source location

    2013-0251-Response-by-Health-Safety-Executive
    Page 2 · response
    Published 4 October 2013

    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

    The provider has ultimate responsibility for identifying and monitoring unsafe conditions and taking appropriate action.

    Verbatim wording from the response

    “The provider has the ultimate responsibility for ensuring that they know and monitor any unsafe conditions in the service and take the correct action.”

    Source location

    2013-0251-Response-by-Care-Quality-Commission
    Page 2 · response
    Published 4 October 2013

    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

    Regulatory action concerning the non-member care home is outside the Association’s authority.

    Verbatim wording from the response

    “The Registered Nursing Home Association is a trade association for owners of care homes providing nursing care (previously called nursing homes). There is no obligation placed upon anyone who joins the Registered Nursing Home Association. The powers of the Association are limited to membership matters, i.e. removing membership where the standards expected of the Association are not met.”

    Source location

    2013-0251-Response-by-RNHA
    Page 1 · response
    Published 4 October 2013

    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

    Regulatory follow-up is assigned to the CQC and HSE, which have the necessary regulatory powers.

    Verbatim wording from the response

    “I see that your report has also been sent to David Bean at CQC and Steve Scott at HSE, both of whom have regulatory powers which I am sure that they will now exercise as necessary.”

    Source location

    2013-0251-Response-by-RNHA
    Page 1 · response
    Published 4 October 2013

    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

    CQC is the lead regulator and inspection body better placed to proactively lead on health and social care service-user safety.

    Verbatim wording from the response

    “I totally understand your concerns but see CQC as the lead regulator and inspection body in England for health and social care providers and we believe they are better placed to proactively lead on service user safety issues. I note that you have also written to CQC.”

    Source location

    2013-0251-Response-by-Health-Safety-Executive
    Page 2 · response
    Published 4 October 2013

    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 authorities enforce health and safety in non-nursing residential care, including relevant standards and compliance concerns.

    Verbatim wording from the response

    “HSE does not routinely inspect health and social care providers but does investigate serious incidents meeting our selection criteria and inspect where there is evidence of poor compliance. This may include, for example, where there is evidence of established standards, such as those covering prevention of burns, not being followed. This is also the case for non-nursing residential care which is enforced by local authorities. I will share this letter with local authority health and safety regulators via HSE’s Local Authority Unit and also arrange for the matter to be discussed at the next meeting of the national local authority practitioner forum.”

    Source location

    2013-0251-Response-by-Health-Safety-Executive
    Page 2 · response
    Published 4 October 2013

    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