Recurring concern

Unreliable access controls for residential accommodation

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First reported 6 Aug 2018•Latest report 4 Mar 2024

Definition

What this concern includes

Includes failures of physical or electronic access controls for residential accommodation, including key-fob systems, locks, gates, doors and associated arrangements intended to keep residential areas or internal routes accessible only through controlled entry.

Not included

  • Excludes emergency-service access arrangements, including key safes, forced entry and responder access to residential or communal premises.
  • Excludes public access to hazardous or officially closed sites where residential accommodation is not the bounded setting.
  • Excludes generic building security, maintenance or resident supervision deficiencies unless they directly make a residential access-control system unreliable.
  • Excludes clinical, custodial and workplace access-control systems unless the assertion explicitly concerns the same residential-accommodation access-control process.
Reports
4

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2018–2024

First to latest report issue date

Stated actions
5

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.

Bournemouth Churches Housing Association Limited1
Crossroads House Care Home1
Future Health and Social Care Association C.I.C.1
London Borough of Camden1
NHS Birmingham and Solihull Integrated Care Board1
NHS England1

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

    Sandra Elizabeth SENIOR · 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

    Sandra Senior travelled to central London on 24 September 2023 and gained access to Tavistock Chambers, where she completed suicide. The report raised concerns that the building’s access-control and safety systems were not operating or being used effectively, allowing unauthorised access, and noted that this was the second similar death there within approximately 18 months.

    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 the front entrance access-control system to secure and permit controlled entry

    Wider context from the report

    “The evidence from a resident of one of the flats in Tavistock Chambers set out that the only access to the residential part of the building is through a door ████████, which has “a secure key fob entry system”. However, the evidence was that “We have constant issues with this front entrance either not locking or not opening with the key, there is also a latch to hook the door open at times”. The witness confirmed that the front entrance was hooked open at the material time; this was confirmed by photographic evidence provided by the Metropolitan Police Service. There was also evidence that approximately a year prior to the events of 24 September 2023, “Camden Council locked the only access ████████ ████████.” The witness had assumed that it remained bolted and locked. However, other evidence, including photographic evidence from the Metropolitan Police Service, showed that although there was a clear ‘no entry’ sign████████, it was not locked shut. A statement from a Detective Sergeant revealed, “A yellow padlock was locked onto the sliding bolt, to give an illusion it was locked, however the clasp had not been held down into the lock, so it could have been opened by any person.” It was also established in evidence that Miss Senior did know any of the residents of Tavistock Chambers or in the vicinity generally. As such, it appeared that her entry to the building ████████ was entirely opportunistic. However, that aside, the evidence suggested that both of the safety systems installed to prevent unauthorised access to the building ████████ were not working effectively at that time. The concern is that it appears that the safety systems in place to stop unauthorised access ████████, in particular, were not operating/being used effectively at the material time and the evidence suggests that this may have been commonplace. ”

    Source location

    Sandra Elizabeth SENIOR · 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

    Failure to secure the secondary access barrier against unauthorised entry

    Wider context from the report

    “The evidence from a resident of one of the flats in Tavistock Chambers set out that the only access to the residential part of the building is through a door ████████, which has “a secure key fob entry system”. However, the evidence was that “We have constant issues with this front entrance either not locking or not opening with the key, there is also a latch to hook the door open at times”. The witness confirmed that the front entrance was hooked open at the material time; this was confirmed by photographic evidence provided by the Metropolitan Police Service. There was also evidence that approximately a year prior to the events of 24 September 2023, “Camden Council locked the only access ████████ ████████.” The witness had assumed that it remained bolted and locked. However, other evidence, including photographic evidence from the Metropolitan Police Service, showed that although there was a clear ‘no entry’ sign████████, it was not locked shut. A statement from a Detective Sergeant revealed, “A yellow padlock was locked onto the sliding bolt, to give an illusion it was locked, however the clasp had not been held down into the lock, so it could have been opened by any person.” It was also established in evidence that Miss Senior did know any of the residents of Tavistock Chambers or in the vicinity generally. As such, it appeared that her entry to the building ████████ was entirely opportunistic. However, that aside, the evidence suggested that both of the safety systems installed to prevent unauthorised access to the building ████████ were not working effectively at that time. The concern is that it appears that the safety systems in place to stop unauthorised access ████████, in particular, were not operating/being used effectively at the material time and the evidence suggests that this may have been commonplace. ”

    Source location

    Sandra Elizabeth SENIOR · 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

    Remove the communal entrance door’s latch and hook to prevent it being held open.

    Verbatim wording from the response

    “On the communal door we have removed the latch and hook so that the door cannot be held in the open position. The door entry system was operational at the time of our visit, and we have a specific contract in place for the maintenance of door entry systems should a fault occur.”

    Source location

    Response from Camden Council
    Page 1 · response
    Published 14 March 2024

    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

    Maintain a specific contract for repairing communal door-entry systems when faults occur.

    Verbatim wording from the response

    “On the communal door we have removed the latch and hook so that the door cannot be held in the open position. The door entry system was operational at the time of our visit, and we have a specific contract in place for the maintenance of door entry systems should a fault occur.”

    Source location

    Response from Camden Council
    Page 1 · response
    Published 14 March 2024

    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

    Inspection frequency cannot be increased because the caretaking service’s frequency is determined by available resources.

    Verbatim wording from the response

    “The caretaking service carries out daily checks and will secure roof top exits and communal entrance doors that are left open or report a fault should there be one. Clearly this can allow some elapsed time between each daily check where a door may be left open, however the frequency of inspection is determined by the resources available for the service. Residents can also report faults, or doors left unlocked, directly to the repairs service.”

    Source location

    Response from Camden Council
    Page 1 · response
    Published 14 March 2024

    Open published response

  2. Dorset

    AI-generated summary

    Tarik Roger Drakes · 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

    Tarik Roger Drakes, who had a history of using heroin, was found collapsed and unresponsive at his supported accommodation on 12 November 2022. He was taken to hospital, where he was found to be in multi-organ failure, and died on 29 November 2022. Concerns were raised about staffing, welfare checks, monitoring, supervision, safeguarding, emergency access, and follow-up of his support needs at the accommodation.

    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 monitor and safeguard access to, and presence within, the accommodation

    Wider context from the report

    “1. During the inquest evidence was heard that: i. Dorset Lodge is a supported housing accommodation facility with 16 rooms that provides accommodation for those who have drug and alcohol addictions. It is owned and managed by Bournemouth Churches Housing Association (BCHA) and they are contracted to provide the housing to residents by BCP Council. It is staffed Monday to Friday, between 8am to 8pm by two support workers, one covering a shift from 8am to 4pm and the other covering a shift from 12noon to 8pm. When the support staff are unavailable, agency staff will cover the support worker role. On Saturdays a support worker is present, but this is not on a contracted basis and if she is on leave there is no cover. Outside the hours of 8am to 8pm, and on weekends, when there is no support worker on site, there is a night response team who will not be on site but attend twice during the night period to conduct perimeter checks of the building. The premises is covered by CCTV, inside and outside, which can be monitored remotely. ii. To provide support to the residents, the support workers will undertake key worker sessions which are offered weekly. When agency staff cover the shifts, when the usual support workers are covering other sites or on leave, they do not undertake key worker sessions. iii. Entry to the premises is gained using a key fob system. Entry is monitored by staff when on site, but between 8pm and 8am, and at weekends when no staff members are on site, residents are able to let people in without any monitoring or safeguarding measures in please. iv. Evidence was given that those at Dorset Lodge are vulnerable due to their addictions. Mr Drakes’ family gave evidence that he had disclosed to them that residents were using drugs within the premises, and they described the times when staff were not present as “party time” with non-residents entering the premises. Even when staff are on duty there is no monitoring of who is in the premises, such as by a signing in and out book. Staff undertake welfare checks upon residents 3 times a day at 10.30am, 3.30pm and 7.30pm, however evidence was given that it is not clear who is present at any one time. v. When the police attended Room 14 at Dorset Lodge on the Thursday 17th November, items of drug paraphernalia were found in the room including needles, a sharps box and a homemade pipe. The room had been insecure from 12th November when Mr Drakes was taken to hospital and there was evidence people had been in the room after that time as items had been removed from the room and residents called the Police to report concerns. vi. Evidence was given by the family that when they attended the premises on the 14th November they tried to call the number on the front door, which was out of hours number, and it was a dead line. Unless a resident allows someone entry, this would be the only route of access to Dorset Lodge by emergency services, such as the paramedics, out of staffed hours to provide care in an emergency, which could delay entry and access to treatment. vii. Mr Drakes was last seen alive on CCTV at Dorset Lodge at 0.44 hours on the 12th November. Paramedics were called at 16.07 hours that day by other residents. As this was a Saturday, and the support worker who did work some Saturdays was not working that day, there were no welfare checks undertaken upon him by staff. It is not possible to say what would have happened if he had been checked by staff or taken to hospital sooner. viii. Mr Drakes was deemed to be vulnerable by the manager at Dorset Lodge and there were professional meetings held to discuss, amongst other things, his placement and need for 24 hour support. The last of these professional meetings was held on the 10th August 2022. One was scheduled for the 9th September 2022 but no one was available and the meeting was not rescheduled prior to the 12th November. There was no follow up meeting about his needs after the meeting on the 9th September did not go ahead. 2. I have concerns with regard to the following: i. That there could be the death of a resident at Dorset Lodge under the current processes in place regarding the monitoring, supervision and safeguarding of residents at Dorset Lodge and I would request that consideration is given to reviewing the current levels of staffing and supervision at the placement, and the processes and procedures in place around support to the residents. ”

    Source location

    Tarik Roger Drakes · 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

    Maintain additional Night Response Team presence at Dorset Lodge during evening hours.

    Verbatim wording from the response

    “NRT have been asked to be present as an additional measure at Dorset Lodge for a couple of hours per night where possible due to a recent increase in activity during March of visitors and some concerns of ASB (Anti-Social Behaviour) which are not related to the concerns highlighted in the inquest of Mr Drakes. This is to determine where this is happening and who is responsible so action can be taken where appropriate. As an organisation we do this as a matter of course when concerns are made known to us. This was identified through routine night checks.”

    Source location

    Response from BCHA
    Page 3 · response
    Published 22 March 2023

    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

    Review the Night Response Team offer to enhance physical evening presence across sites.

    Verbatim wording from the response

    “The NRT service undertake a perimeter check where possible nightly across the properties that are covered. This consists of a walk around the building, checking any safety issues, ensuring doors are closed and secured, emergency lighting is working, barriers are working, no damage and no intruders in the vicinity. At some services, the NRT have also supported customers who have been locked out of the building to gain entrance when available. This is supported at Dorset Lodge on occasion. CCTV is not ‘monitored’ through the night but there is currently remote access which can be viewed/accessed if required. We are currently undertaking a review of our NRT offer which we hope will allow for greater physical presence across sites through the evening.”

    Source location

    Response from BCHA
    Page 3 · response
    Published 22 March 2023

    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

    A signing-in book was not required for this HMO, and the accommodation was fully fire compliant under applicable legislation.

    Verbatim wording from the response

    “Dorset Lodge is not a secure living facility and there is no requirement on site for customers to complete a signing in book, guests are always the responsibility of tenants. As an HMO there is no requirement for a signing in book for fire safety reasons. Dorset Lodge is fully fire compliant as per legislation.”

    Source location

    Response from BCHA
    Page 5 · response
    Published 22 March 2023

    Open published response

  3. Birmingham and Solihull

    AI-generated summary

    Simon Anthony Graham · 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

    Simon Anthony Graham, who had recently attempted suicide by overdose, died by suspension from a ligature at a respite centre on 4 May 2018. The report raised concerns about lone working, delays caused by incorrectly labelled room keys, unqualified support workers undertaking suicide risk assessments, and incomplete suicide prevention 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 maintain accurate room-key labelling

    Wider context from the report

    “3. Concern 2: Support workers were using keys to check on residents in their rooms knowing that they were labelled incorrectly. The fact Simon Graham’s room key was incorrectly labelled added to the delayed entry to the room and emergency first aid. I heard evidence that after the death of Simon Graham all keys were checked to ensure they were labelled correctly. However, Future Care & Social Care Association want to implement a key fob system, to avoid any confusion and provide quick access in an emergency, but this has still not been implemented. Further funding would be required to implement a key fob system. ”

    Source location

    Simon Anthony Graham · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Cornwall and Isles of Scilly

    AI-generated summary

    Phyllis Margaret LETCHER · 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

    Phyllis Margaret Letcher died after sustaining a traumatic head injury in an unwitnessed fall down the staircase at Crossroads House Care Home on 2 March 2018; she died on 12 March 2018. The concerns identified were the lack of live CCTV monitoring of the staircase, the absence of key-fob access through the stairgate, and the absence of an alarm if the stairgate was left open.

    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 key fob access control through the stairgate

    Wider context from the report

    “(2) The absence of a key fob access through the stairgate. The court heard evidence that whilst access from the residential quarters is controlled by key fob there is no such control of access to the staircase. ”

    Source location

    Phyllis Margaret LETCHER · 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

    Consider the safety consequences and feasibility of adding key-fob access controls to stair gates.

    Verbatim wording from the response

    “2. We have considered your concern that we should add key fob access to the stair gates. We have then considered the consequences if key fob access had been in place at the time of Mrs Letcher’s admission. Since she had the required mental capacity to make her own decisions in relation to mobility and transfers, it is highly likely that we would have needed to provide her with a fob in order to prevent an unlawful restriction on her movements and”

    Source location

    2018-0276-Response-by-Anson-Care-Services-Limited
    Page 5 · response
    Published 30 October 2018

    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

    Key-fob access would probably not have prevented the fall because the resident would have been entitled to receive a fob and retain stair access.

    Verbatim wording from the response

    “2. We have considered your concern that we should add key fob access to the stair gates. We have then considered the consequences if key fob access had been in place at the time of Mrs Letcher’s admission. Since she had the required mental capacity to make her own decisions in relation to mobility and transfers, it is highly likely that we would have needed to provide her with a fob in order to prevent an unlawful restriction on her movements and”

    Source location

    2018-0276-Response-by-Anson-Care-Services-Limited
    Page 5 · response
    Published 30 October 2018

    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

    Key-fob stair access is constrained by the need for extensive fire-system cabling and risks from automatic release or displaced falls.

    Verbatim wording from the response

    “There is the further practical complication that such fobs would need to be linked to the fire alarm system so that they release automatically in the event of a fire. This would require extensive additional fire cabling supply to each level. Automatic release of fire escape routes presents its own challenges and risks for people with dementia – especially as the fire alarms can often be ‘set off’ by service users with dementia.”

    Source location

    2018-0276-Response-by-Anson-Care-Services-Limited
    Page 6 · response
    Published 30 October 2018

    Open published response
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Data last updated 7 September 2026