Recurring concern

Unreliable Safe and Well Visit risk-assessment and review processes

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First reported 11 Sep 2017•Latest report 23 Nov 2023

Definition

What this concern includes

Includes failures in the dedicated Safe and Well Visit process, including identifying and referring relevant fire risks, conducting visits and risk assessments, assigning appropriate independent oversight, reviewing high-risk cases and reassessing risk when circumstances change.

Not included

  • Excludes generic fire-risk assessment or home-visit deficiencies where the Safe and Well Visit process is not explicitly involved.
  • Excludes routine fire-safety advice, equipment provision or remedial works that are not part of a Safe and Well Visit arrangement.
  • Excludes generic care-plan, risk-assessment or audit deficiencies unrelated to Safe and Well Visits.
  • Excludes failures occurring after a Safe and Well Visit has been completed where the deficient condition is a separate downstream fire-safety or care process.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2017–2023

First to latest report issue date

Stated actions
1

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.

Great Places Housing Association1
Manchester City Council1
NHS Greater Manchester Integrated Care Board1
Surrey County Council1

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. Surrey

    AI-generated summary

    Kevin Stephen O’Hara · 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

    Kevin Stephen O’Hara, who was bedbound and lived alone with carers visiting four times a day, died in a fire at his home on 7 February 2023 after a lit cigarette ignited debris on a mattress used as a crash mat. The fire produced significant smoke and was detected only after smoke seeped through a closed living-room door to a hallway alarm. Concerns included inadequate review and oversight of Safe and Well Visits by Surrey Fire and Rescue Service, and insufficient oversight by Surrey Adult Social Care to ensure that required risk assessments followed visits.

    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

    High-risk reviews being undertaken by the officer who conducted the initial Safe and Well Visit

    Wider context from the report

    “That SFRS reviews of individuals deemed high risk, are usually undertaken by the officer who conducted the initial Safe and Well Visit with the risk that opportunities for oversight and reassessment are missed. ”

    Source location

    Kevin Stephen O’Hara · Prevention of Future Deaths report
    Page 3 · 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 review or audit of completed Safe and Well Visits

    Wider context from the report

    “Evidence was given that the Safe and Well Visit in November 2022 was conducted by an inexperienced officer. The results of that visit did not seem to be subject to any scrutiny. SFRS do not appear to have in place a system of review or audit by line managers or more experienced staff of completed Safe and Well Visits, with the risk, as in this case, that errors or issues requiring action are not identified. ”

    Source location

    Kevin Stephen O’Hara · 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

    Develop and implement formal Safe and Well Visit quality assurance, including annual team shadowing, recording and safe-to-deliver certification.

    Verbatim wording from the response

    “Once assessed as competent, SWVs will be carried out by a staff member without being shadowed. However, there is a system of informal support throughout the Community Safety Team and any questions or concerns can be highlighted at any time before, during or after a visit, with assistance being given from the Partnership coordinator or any team member. This is currently an informal process that is not documented in a policy. As a result of the Coroner’s concerns and an His Majesty's Inspectorate of Constabularies and Fire Rescue Services (HMICFRS) inspection, a formal Quality Assurance process is now being developed (see below).”

    Source location

    Response from Surrey
    Page 4 · response
    Published 29 November 2023

    Open published response

  2. Manchester City

    AI-generated summary

    Mr Brian MacLean · 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

    Mr Brian MacLean died on 19 March 2016 from smoke inhalation contributed to by alcohol toxicity after a fire started while he was smoking on his sofa. The report raised concerns about insufficiently proactive social services involvement, failure to identify and refer him as being at risk of fire, and the absence of automatic processes for fire-risk assessment, referrals, sprinklers and other preventive measures.

    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 GPHA to make referrals to GMFRS for safe and well visits

    Wider context from the report

    “3. There was no process for GPHA to automatically consider fire risks and prevention and make referrals to GMFRS for safe and well visits. ”

    Source location

    Mr Brian MacLean · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
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Data last updated 7 September 2026