Recurring concern

Unreliable multi-agency control of home fire risks for vulnerable residents

First to latest report 14 Dec 2018 — 3 Oct 2024

Reports that mention this concern: 2
Times this concern has been raised: 3
Stated actions linked to this concern: 8

What this concern includes

Includes failures in multi-agency arrangements specifically intended to identify, reassess, communicate, assign responsibility for and reduce fire risks in the homes of vulnerable residents, including serious mental illness, self-neglect, hoarding or smoking-related fire risks; include environmental inspections, risk-management plans, information sharing, clearance or other agreed remedial action where these directly control the home fire risk.

What is not included

Excludes generic multi-agency ownership, communication or care-coordination failures where a material home fire risk is not identified.
Excludes general fire-risk assessments, fire alarms, sprinklers, evacuation or fire-safety standards when the concern is not the coordinated control of a vulnerable resident's home fire risk.
Excludes accommodation repair or maintenance failures unrelated to a known home fire risk.
Excludes generic self-neglect, hoarding or mental-health care failures where no home fire-risk control is asserted.
Excludes fire-service referral or Safe and Well Visit failures after the relevant home fire-risk referral process is the primary deficient boundary.

Trends

Reports over time

Reports mentioning this concern, 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.

London Borough of Newham1

London Fire Brigade1

Office of the Chief Coroner1

South West Yorkshire Partnership Teaching NHS Foundation Trust1

Together Housing Group Limited1

West Yorkshire Fire and Rescue Service1

Reports and published responses 2 reports

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

3 Oct2024
East London
Concerns raised1
1. Absence of a risk management plan to reduce fire harm
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

London Borough of Newham
London Fire Brigade
Stated actions 3
1. London Borough of Newham
  Hold training for social care staff on fire safety risk assessment and risk management plans.
2. London Borough of Newham
  Produce a briefing on developing fire safety risk management plans, covering escalation, LFB feedback, and plan reviews.
3. London Borough of Newham
  Conduct enhanced monitoring for people known to Adult Social Care who have an established fire risk, for one year.
Respondent positions 2
1. London Fire Brigade
  The statutory fire service role does not include responsibility for an individual resident’s care plan or personalised risk management plan.
  Outside remit
1. London Fire Brigade
  Care providers are responsible for planning and delivering care based on risk assessments, including assessing and mitigating fire risk.
  Redirects responsibility
AI-generated summary

Mrs Gabrielle Sarah Anne Steel · 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

Mrs Gabrielle Sarah Anne Steel, who was bed bound and known to smoke in bed and drink alcohol, died after a fire on her bed at her home on 17 October 2023. The fire investigation identified the likely cause as unsafe disposal of smoking materials, and the flame-retardant duvet cover was not on the bed. The principal concerns were poor communication of the fire safety assessment and the absence of a shared written fire risk management plan for those caring for her.

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
Absence of a risk management plan to reduce fire harm
Wider context from the report
“1. The risk of fire, due to smoking in bed was recognised by a local authority occupational therapist. A request was made to the London Fire Brigade for a home fire safety visit. The assessment took place promptly, but neither the occupational therapist, nor the social worker enquired into the outcome of the home fire safety visit, so that a risk management plan could be put in place. 2. The findings of the home fire safety visit were shared only with Mrs Steel – a vulnerable, elderly lady. The findings were not conveyed to those with responsibility for caring for her. 3. A written risk assessment/risk management plan was completed by the London Fire Brigade. This was not left in the property or shared with Mrs Steel, her family, her carers or the agency who requested the fire safety check. 4. As a result of the poor communication from the LFB, there was no risk management plan in place to reduce the risk of fire harm to Mrs Steel. Had the findings of the fire assessor been communicated, carers would have been aware of the need to re-iterate the importance of stubbing out cigarettes in an ashtray and not leaving cigarettes to burn out; the need to dispose of all non-flame retardant bedding, to ensure that the safe bedding was in place at all times; the importance of keeping extraneous flammable materials away from the bed, as much as possible. ”
Source location
Mrs Gabrielle Sarah Anne Steel · 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
Hold training for social care staff on fire safety risk assessment and risk management plans.

Verbatim wording from the response
“2. Action: To further improve training for social care staff by holding a training session on fire safety risk assessment and risk management plans. This session will complement the joint training session which took place on 25/04/24. Who: Workforce Development and Strategic Safeguarding When: 30/01/25”

Source location
Response from London Borough of Newham
Page 1 · response
Published 4 October 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
Produce a briefing on developing fire safety risk management plans, covering escalation, LFB feedback, and plan reviews.

Verbatim wording from the response
“3. Action: Produce a ‘7 minute briefing on the development of fire safety risk management”

Source location
Response from London Borough of Newham
Page 1 · response
Published 4 October 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
Conduct enhanced monitoring for people known to Adult Social Care who have an established fire risk, for one year.

Verbatim wording from the response
“4. Action: Enhanced monitoring where there is an established risk of fire for people known to Adult Social Care. The monitoring will take place for the next year with the objective of ensuring learning is embedded. Who: Strategic Safeguarding When: Monitoring to start from 2025”

Source location
Response from London Borough of Newham
Page 2 · response
Published 4 October 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
The statutory fire service role does not include responsibility for an individual resident’s care plan or personalised risk management plan.

Verbatim wording from the response
“The Fire Service's statutory role does not include responsibility for a resident's care plan or for making or contributing to a personalised risk management plan for an individual resident. The purpose of a Home Fire Safety Visit is to provide advice and guidance to help keep the resident safe. At a Home Fire Safety Visit, LFB staff record advice given on a data collection form which is then uploaded into a database. In most cases this information is recorded using a tablet which will populate the database automatically. Existing LFB policy, which follows national best practice, does not authorise staff to share findings with any other person and currently no functionality to be able to leave a copy of the findings with the resident.”

Source location
Response from London Fire Brigade
Page 2 · response
Published 4 October 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
Care providers are responsible for planning and delivering care based on risk assessments, including assessing and mitigating fire risk.

Verbatim wording from the response
“The Fire Service's statutory role does not include responsibility for a resident's care plan or for making or contributing to a personalised risk management plan for an individual resident. Home Fire Safety Visits are not intended to be personal risk assessments but to be provision of fire safety advice to the resident. Care providers are regulated to plan and deliver care based on risk assessments, and this should include assessing risk from fire. A care provider should not need an HFSV to prompt attention on any of the points raised above. However, we accept that there is learning around communication with the carer about identified fire risk within the limitations of UK GDPR/Data Protection A 2018 and for the HFSV process to reinforce the need for care providers to have regard to fire safety. We have set out above that we are taking steps to explore improvements.”

Source location
Response from London Fire Brigade
Page 2 · response
Published 4 October 2024
Open published response
14 Dec2018
West Yorkshire (West)
Concerns raised2
1. Failure to carry out regular property inspections and provide assistance
2. Lack of collective or assigned responsibility for reducing home fire risk
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

South West Yorkshire Partnership Teaching NHS Foundation Trust
Together Housing Group Limited
Stated actions 5
1. Together Housing Group Limited
  Develop a vulnerability database to identify higher-risk tenants and update relevant information annually and at key tenancy or safeguarding points.
2. Together Housing Group Limited
  Resume regular tenancy audits focused on tenants with no recent contact or identified vulnerability, including property inspections where access is permitted.
3. Together Housing Group Limited
  Assign the Fire Safety Group responsibility for monitoring, learning lessons and making risk-reduction policy decisions.
1. Together Housing Group Limited
  Amend the hoarding procedure and link it to local arrangements, including the Kirklees Hoarding Panel.
2. South West Yorkshire Partnership Teaching NHS Foundation Trust
  Reinforce inclusion of family and carers in care planning and risk management through training, the information leaflet and staff alert.
Respondent positions 1
1. South West Yorkshire Partnership Teaching NHS Foundation Trust
  Management of people facing multiple risks is not solely the Trust’s responsibility and requires housing, fire and rescue, family, and carer involvement.
  Redirects responsibility
AI-generated summary

BARNABY LUKE AYLWARD · 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

Barnaby Luke Aylward died in the early hours of 4 September 2017 after being overcome by smoke from an accidental house fire caused more likely than not by a lit cigarette. The report identified concerns about known fire risks associated with his heavy smoking, clutter and serious mental illness, including insufficient multi-agency risk assessment, information sharing, property inspection, care planning and preventative support.

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 carry out regular property inspections and provide assistance
Wider context from the report
“(1) Mr Aylward was a social housing tenant. He exhibited certain behaviours that were in part linked to his serious mental illness. Those presented risk of death in a fire at home including heavy smoking and allowing clutter and waste to accumulate there. Those behaviours and thus the risks were known to certain individuals, including his family, and agencies but they did not except in time of crisis or emergency: a) review those potential risks with a multi agency preventative approach and re assess those risks regularly over time; b) take any collective responsibility nor for any one person or agency to take responsibility to reduce or eliminate risk by action eg clearing clutter and fire risk; and education about risk and reluctance to compel Mr Aylward to improve his environment regularly if needed; c) did not feel empowered to make property inspections regularly or at all and advise Mr Aylward and other agencies, or have sufficient resources at the right level to inspect and assist; d) may have been hampered by issues of confidentiality in communications between agencies. If all agencies had shared the particulars of his behaviours the burden of risk might be shared and understood and potential to reduce or eliminate the risk attempted, reviewed and managed. ”
Source location
BARNABY LUKE AYLWARD · 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
Lack of collective or assigned responsibility for reducing home fire risk
Wider context from the report
“(1) Mr Aylward was a social housing tenant. He exhibited certain behaviours that were in part linked to his serious mental illness. Those presented risk of death in a fire at home including heavy smoking and allowing clutter and waste to accumulate there. Those behaviours and thus the risks were known to certain individuals, including his family, and agencies but they did not except in time of crisis or emergency: a) review those potential risks with a multi agency preventative approach and re assess those risks regularly over time; b) take any collective responsibility nor for any one person or agency to take responsibility to reduce or eliminate risk by action eg clearing clutter and fire risk; and education about risk and reluctance to compel Mr Aylward to improve his environment regularly if needed; c) did not feel empowered to make property inspections regularly or at all and advise Mr Aylward and other agencies, or have sufficient resources at the right level to inspect and assist; d) may have been hampered by issues of confidentiality in communications between agencies. If all agencies had shared the particulars of his behaviours the burden of risk might be shared and understood and potential to reduce or eliminate the risk attempted, reviewed and managed. ”
Source location
BARNABY LUKE AYLWARD · 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
Develop a vulnerability database to identify higher-risk tenants and update relevant information annually and at key tenancy or safeguarding points.

Verbatim wording from the response
“3.1 Information about our customers - We are developing further our database in relation to vulnerabilities including those related to fire risks. Annually we will update personal information from higher risk customers particularly those in supported housing and high rise flats. This database is aimed at ensuring we identify higher risk tenants and causes, it requests details on health and lifestyle issues. We request this data from tenants and where appropriate arrange joint safe and well visits with the fire service. The information is updated annually but also used at the start of new tenancies or where officers identify a safeguarding issue with a tenant.”

Source location
2018-0387-Responses
Page 4 · response
Published 13 May 2019
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
Resume regular tenancy audits focused on tenants with no recent contact or identified vulnerability, including property inspections where access is permitted.

Verbatim wording from the response
“4.2 Tenancy Audits - From April 2019 we are resuming regular visits to tenants, this programme of visits will focus on those where we have had no previous contact (eg via repairs or gas servicing) or have had concerns regarding vulnerability. These will include a property inspection where tenants will allow access. Any issues of concern will be acted upon via tenancy safeguarding procedures.”

Source location
2018-0387-Responses
Page 5 · response
Published 13 May 2019
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
Assign the Fire Safety Group responsibility for monitoring, learning lessons and making risk-reduction policy decisions.

Verbatim wording from the response
“3.4 Strategic Fire Safety Group - The existing Fire Safety Group will take responsibility for monitoring, learning lessons and taking policy decisions where appropriate to reduce risks. The group consists of officers from across the Together Housing Group alongside representatives from the West Yorkshire Fire and Rescue Service.”

Source location
2018-0387-Responses
Page 5 · response
Published 13 May 2019
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
Amend the hoarding procedure and link it to local arrangements, including the Kirklees Hoarding Panel.

Verbatim wording from the response
“3.5 Hoarding - We have introduced a new approach to hoarding and all relevant colleagues have now undergone training in how to recognise and deal with tenants in these situations. We will by the end of March 2019 have amended the hoarding procedure and included links to local arrangements including the Kirklees Hoarding panel.”

Source location
2018-0387-Responses
Page 5 · response
Published 13 May 2019
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
Reinforce inclusion of family and carers in care planning and risk management through training, the information leaflet and staff alert.

Verbatim wording from the response
“Learning events have previously been provided by the safeguarding team which includes raising awareness to include carers and family in care planning and risk management, this will continue to be reinforced through our mandatory and core clinical training programmes. This will be reinforced through the publication of the above mentioned information leaflet and alert.”

Source location
2018-0387-Responses
Page 9 · response
Published 13 May 2019
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
Management of people facing multiple risks is not solely the Trust’s responsibility and requires housing, fire and rescue, family, and carer involvement.

Verbatim wording from the response
“The Trust has in place guidance in various forms to assist staff in supporting service users who may be vulnerable. There are a number of partnership arrangements where both health and local authority work together to provide care and treatment to people in the community. It is important that staff from all agencies recognise that the management of a person who may be at risk for a number of reasons is not the sole responsibility of one agency. Going forward Trust staff should be encouraged to use the knowledge and expertise of other agencies such as housing and fire and rescue services. The knowledge of family and carers is also a very important element when caring for vulnerable people.”

Source location
2018-0387-Responses
Page 8 · response
Published 13 May 2019
Open published response