Recurring concern

Inadequate fire risk assessments

First to latest report 3 Jun 2014 — 19 Apr 2026

Reports that mention this concern
5
Times this concern has been raised
6
Stated actions linked to this concern
4

What this concern includes

Includes failures of the dedicated fire risk assessment process to identify, assess, document and address material fire-safety risks, including unresolved prior actions and risks affecting vulnerable occupants or people unable to self-evacuate.

What is not included
  • Excludes failures to implement fire-safety measures after an otherwise adequate assessment where the assessment itself is not deficient.
  • Excludes general fire-safety standards or guidance that are unclear but where the assessment process is otherwise adequate.
  • Excludes physical fire hazards, evacuation, alarm, sprinkler and other fire controls unless the reported deficiency is specifically a failure of the fire risk assessment process.
  • Excludes failures limited solely to reassessing after a material change when no broader inadequacy of the fire risk assessment is identified; that concern is covered by the existing material-change fire-risk-assessment parent.

Reports and published responses 5 reports

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

  1. West London

    AI-generated summary

    Paul HUTCHINSON · 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

    Paul HUTCHINSON died of burns after setting himself alight while smoking in his Extra Care Sheltered Accommodation on 21 January 2025. The report raised concerns about the lack of specific requirements for individual fire risk and evacuation assessments, non-standardised staff training, and whether fire risk assessments adequately considered vulnerable residents who may be unable to self-evacuate.

    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 Fire Risk Assessments to account for vulnerable residents at special risk

    Wider context from the report

    “3. Fire Risk Assessments for premises providing ECSA and sheltered accommodation more generally may not contemplate vulnerable residents as forming 'any group of persons identified...as being especially at risk' (see article 9(7)(b) of the 2005 Regulations). Vulnerable residents may be at special risk because of (for example) smoking or cooking practices and may have a compromised ability to self-evacuate. The concern is that Fire Risk Assessments do not take this into account. ”

    Source location

    Paul HUTCHINSON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Suffolk

    AI-generated summary

    Ruth Ann PINGREE · 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

    Ruth Ann Pingree died after an accidental fire engulfed the caravan in which she was holidaying with her family. The caravan door became jammed, the smoke detector did not activate, and she was unable to escape before being overcome by fire fumes. The report raised concerns about a lack of clear standards for fire safety measures, risk assessments, and assurance and enforcement for businesses providing paid 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

    Lack of defined guidance, format, scope and frequency for fire-safety risk assessments

    Wider context from the report

    “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO). In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO. This does not require that the proprietors: . keep any written records; . set a specific interval of maintenance inspections; or . provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency. There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted. Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take. The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc. This is in the context of businesses providing accommodation to the public on a paid basis. There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this. ”

    Source location

    Ruth Ann PINGREE · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. North London

    AI-generated summary

    Sean Ennis · 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

    Sean Ennis was found in his flat after a fire and died in hospital from the consequences of smoke inhalation. The principal concerns included incomplete fire-risk assessment and inadequate smoke detection and telecare arrangements for a vulnerable resident, including the alarm centre not knowing he was a smoker and not responding when he did not answer calls.

    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 comprehensive fire risk assessments

    Wider context from the report

    “1. All Responsible Persons should carry out a comprehensive fire risk assessment that details the fire safety provisions that are in the property and where identified ensure that the recommended safety measures have been applied. It is not appropriate to ‘carry over’ identified actions from one fire risk assessment to another, without addressing those risks. ”

    Source location

    Sean Ennis · Prevention of Future Deaths report
    Page 1 · 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 address identified fire risks from fire risk assessments

    Wider context from the report

    “1. All Responsible Persons should carry out a comprehensive fire risk assessment that details the fire safety provisions that are in the property and where identified ensure that the recommended safety measures have been applied. It is not appropriate to ‘carry over’ identified actions from one fire risk assessment to another, without addressing those risks. ”

    Source location

    Sean Ennis · 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

    Conduct annual fire risk assessments and assign risk-based target dates to improvements or additional requirements identified.

    Verbatim wording from the response

    “35. NH has carried out a comprehensive Fire Risk Assessment for all of the areas of premises for which it is the Responsible Person. Fire Risk Assessments are reviewed every year at this site, or sooner if there is a significant change in the premises.”

    Source location

    2022-0054-Response-from-Network-Homes_Published.pdf
    Page 7 · response
    Published 24 February 2022

    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

    Fire safety obligations under the Regulatory Reform (Fire Safety) Order do not apply to individual flats or activities within them.

    Verbatim wording from the response

    “14. Under Article 6(1)(a) RRO, none of the obligations under RRO (save in relation to Prohibition Notices, which is irrelevant here) apply to domestic premises. This means that, although the common parts of sheltered housing buildings (corridors, stairways etc) are covered by RRO, the individual flats themselves are not.”

    Source location

    2022-0054-Response-from-Network-Homes_Published.pdf
    Page 3 · response
    Published 24 February 2022

    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

    Responsibility for fire risk assessment at the property is outside the respondent’s ownership and borough remit, except for actions directly affecting its service.

    Verbatim wording from the response

    “1) Whilst the property at Knighleas Court is not within the borough of Barnet, nor owned or managed by Barnet Homes, we undertake to co-operate with any actions carried out as part of a fire risk assessment that directly affect the service provided by Barnet Homes.”

    Source location

    2022-0054-Response-from-Barnet-Homes_Published.pdf
    Page 1 · response
    Published 24 February 2022

    Open published response

  4. North Wales (East and Central)

    AI-generated summary

    Bernard Hender and Douglas McTavish · 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

    Bernard Hender and Douglas McTavish died on 10 October 2014 after a fire at their shared flat, with the deaths attributed to smoke inhalation and carbon monoxide poisoning. The inquest found, on the balance of probabilities, that the fire was caused by an electrical fault in a tumble dryer. Concerns included Whirlpool’s assessment and use of information about fire risks associated with door switch assemblies, and insufficient public awareness of the risk of fires caused by spontaneous combustion.

    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 risk assessments to identify and appreciate the extent of fire risk

    Wider context from the report

    “[1] The door switch assembly of interest in this case is used in literally hundreds of thousands of appliances manufactured by Whirlpool. I did not emerge from the hearing confident that Whirlpool’s risk assessment processed have fully identified or appreciated the extent of the risk of fire (and its potential consequences). My impression was that at least some of the evidence from those called at the request of Whirlpool was defensive and dismissive in nature. The description by the company’s former Global Product Safety Director of the company’s approach to what he described as ‘soft data’ from the field (meaning, amongst other things, reported instances of fires) was of considerable concern to me. I am concerned that the company’s reluctance to place due reliance on information coming forward in this way, and instead to prefer to take advice from itself, represents an obstacle to timely learning and a likely inhibitor to progressive steps which might prevent fires and save lives. [2] In the course of evidence ████████ spoke about his belief that the most likely cause of the fire being spontaneous combustion, and explained that he was aware of hundreds of fires of that origin. I was not sure that public awareness of the magnitude of the risk and of the circumstances in which it might materialise reflects the picture painted by ████████. I am concerned that not enough has been done historically to raise awareness of this risk. ”

    Source location

    Bernard Hender and Douglas McTavish · 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

    Continue applying product-safety processes and monitoring field and external reports involving potential fire risks.

    Verbatim wording from the response

    “Whirlpool has a comprehensive set of policies, procedures, and guidelines in place for field monitoring, field safety investigations, analysis, risk assessment, and reporting potential safety hazards associated with its products. These systems have been developed and refined over decades, and Whirlpool keeps those systems under review as part of its commitment to continual improvement.”

    Source location

    2017-0311-Response-by-Whirlpool-UK-Appliances-Limited
    Page 1 · response
    Published 28 November 2017

    Open published response

  5. Wiltshire and Swindon

    AI-generated summary

    Private Robert WOOD and Private Dean HUTCHINSON · 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

    Private Robert Wood and Private Dean Hutchinson died on 14 February 2011 from inhalation of products of combustion and severe burns. The report raised concerns about fire risk assessments, training on electrical appliance overloading, identification of sleeping in office accommodation, and the effectiveness of random overnight checks.

    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 fire risk assessments to identify sleeping in office accommodation

    Wider context from the report

    “(3) A copy of the fire risk assessment is, of course, given to the relevant Fire NCO and, of course, the sleeping issue is very much highlighted to all fire risk assessment assessors. In the actual fire risk assessment of the General Support Squadron area that was undertaken on the 3 December 2010 it was not picked up by the relevant fire NCO who, of course, subsequently received a copy of the document stating that sleeping was not taking place. I would be grateful if you could please review the matter in relation to the risk assessment document with a view to considering whether it would be sensible to put a note possibly in bold and/or even capitals on the subject of the declaration in relation to sleeping in office accommodation to act as a reminder to the Fire NCO to check the point. Whilst ████████ referred to the guidance, referring to the use of cots/beds, soldiers of course are resourceful and will sleep at a desk or even on the floor. ”

    Source location

    Private Robert WOOD and Private Dean HUTCHINSON · 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

    Continue reviewing the DFRMO Fire Risk Assessment template to emphasise recording sleeping on premises regardless of primary purpose.

    Verbatim wording from the response

    “Your third concern has been addressed as part of the ongoing review of the DFRMO Fire Risk Assessment template. The template has been updated to further emphasise the need to record if any sleeping is taking place on the premises regardless of its primary purpose. The review is not yet complete but I have attached the latest draft with the changes highlighted for your information. The revised version is planned to be implemented by the end of October 2014.”

    Source location

    2014-0556-Response
    Page 1 · response
    Published 3 June 2014

    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

    Implement the revised DFRMO Fire Risk Assessment template across Defence by the end of October 2014.

    Verbatim wording from the response

    “Your third concern has been addressed as part of the ongoing review of the DFRMO Fire Risk Assessment template. The template has been updated to further emphasise the need to record if any sleeping is taking place on the premises regardless of its primary purpose. The review is not yet complete but I have attached the latest draft with the changes highlighted for your information. The revised version is planned to be implemented by the end of October 2014.”

    Source location

    2014-0556-Response
    Page 1 · response
    Published 3 June 2014

    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