8 Jun 2016 Stephen Alan HUNT · Prevention of Future Deaths report Manchester City
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Concerns raised 15 Inadequate guidance and training on the limited reliability of thermal imaging cameras for measuring ambient temperature View source Lack of effective means to ensure fire and rescue services meet expectations and disseminate national learning View source Inadequate training and guidance to recognise the effects of heat and appropriate withdrawal steps View source Failure to record significant hazards and safety control measures within each sector View source Failure to deploy aerial monitors without compromising personnel safety in the risk area View source Failure of incident role handovers to capture and share key safety information View source Inadequate training and guidance to enable personnel to withdraw colleagues adversely affected by heat View source Inadequate training and guidance to enable personnel to withdraw themselves from heat exposure View source Failure to define the circumstances for inspections under section 7(2)(d) of the Fire and Rescue Services Act 2004 View source Loss of communications at operational incidents View source Lack of means for responsible persons to verify fire risk assessor competence View source Failure to control breathing-apparatus wear duration according to relevant heat-exposure factors View source Inadequate training and qualification of fire risk assessors View source Failure to test whether national learning is received, understood, actioned and embedded View source Failure to pass hazard and safety-control information to the incident command team for analytical risk assessment View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Stephen Alan HUNT · 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 Alan Hunt, a firefighter, died after entering a fire at Paul's Hair and Beauty World in Manchester on 13 July 2013. He was found inside the premises after suffering heat exhaustion and hypoxia. The principal concerns included failures in communication and handover, misinterpretation of instructions, loss of telemetry and radio communications, inadequate fire risk assessments and fire safety measures, and decisions affecting firefighter safety.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chief Fire and Rescue Adviser; that does not assign responsibility.
PFD Monitor interpretation Inadequate guidance and training on the limited reliability of thermal imaging cameras for measuring ambient temperature
Wider context from the report “(5) It is suggested that all FRSs should undertake a review to ensure the adequacy of standard operating procedures, guidance and training in the appropriate use of thermal imaging cameras to include the limited extent to which they can be relied upon to measure ambient temperature .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chief Fire and Rescue Adviser; that does not assign responsibility.
PFD Monitor interpretation Lack of effective means to ensure fire and rescue services meet expectations and disseminate national learning
Wider context from the report “(10) It is understood that there are some 45 Fire and Rescue Services and the findings of the inquest need to be disseminated down to them all. The pressure is upon them to find their own solutions to problems against the backdrop of financial pressures. The Home Office now leads on fire issues and there has been ever increasing decentralisation. Whilst this is not without merit there appear to be difficulties in ensuring that services are meeting expectations and a means of disseminating national learning.
It is suggested that consideration is given to being able to mobilise a national and consistent approach to sharing the learning and testing so that it can be shown to be received, understood, actioned and embedded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chief Fire and Rescue Adviser; that does not assign responsibility.
PFD Monitor interpretation Inadequate training and guidance to recognise the effects of heat and appropriate withdrawal steps
Wider context from the report “(1) It is suggested that all Fire and Rescue Services (FRS's) should consider the implementation of measures to reduce the risks associated with the physiological affects of working in a hot environment. In particular consideration should be given to:
Duration of wears under breathing apparatus;
Having regard to all relevant factors including, for example the weather, previous exertions of BA teams and individual circumstances;
Training and guidance for all operational personnel to recognize the effects of heat both on themselves and on their colleagues and the appropriate steps to take upon such recognition, including withdrawal and self withdrawal.
Training and guidance for all operational personnel to have the ability and confidence to ensure the withdrawal of others who may be adversely affected by heat whether by calling a BA emergency or otherwise appropriately.
Training and guidance for all operational personnel to have the ability and confidence to withdraw themselves by whatever means appropriate including activating the ADSU.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chief Fire and Rescue Adviser; that does not assign responsibility.
PFD Monitor interpretation Failure to record significant hazards and safety control measures within each sector
Wider context from the report “(4) It is suggested that all FRSs should ensure that significant hazards and any safety control measures are the responsibility of the incident commander and should be recorded within each sector, to ensure visibility to all on the fireground, and passed/copied for use by the incident commander/command team to assist on the analytical risk assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chief Fire and Rescue Adviser; that does not assign responsibility.
PFD Monitor interpretation Failure to deploy aerial monitors without compromising personnel safety in the risk area
Wider context from the report “(6) It is suggested that all FRSs should undertake a review to ensure the adequacy of standard operating procedures, guidance and training in the deployment of aerial monitors to ensure the safety of any personnel within the risk area is not compromised.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chief Fire and Rescue Adviser; that does not assign responsibility.
PFD Monitor interpretation Failure of incident role handovers to capture and share key safety information
Wider context from the report “(3) It is suggested that all FRSs should undertake a review to ensure the adequacy of standard operating procedures, guidance and training of the handing over and taking over of roles at incidents to ensure all the key areas of information, including safety control measures, are captured and shared.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chief Fire and Rescue Adviser; that does not assign responsibility.
PFD Monitor interpretation Inadequate training and guidance to enable personnel to withdraw colleagues adversely affected by heat
Wider context from the report “(1) It is suggested that all Fire and Rescue Services (FRS's) should consider the implementation of measures to reduce the risks associated with the physiological affects of working in a hot environment. In particular consideration should be given to:
Duration of wears under breathing apparatus;
Having regard to all relevant factors including, for example the weather, previous exertions of BA teams and individual circumstances;
Training and guidance for all operational personnel to recognize the effects of heat both on themselves and on their colleagues and the appropriate steps to take upon such recognition, including withdrawal and self withdrawal.
Training and guidance for all operational personnel to have the ability and confidence to ensure the withdrawal of others who may be adversely affected by heat whether by calling a BA emergency or otherwise appropriately.
Training and guidance for all operational personnel to have the ability and confidence to withdraw themselves by whatever means appropriate including activating the ADSU.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chief Fire and Rescue Adviser; that does not assign responsibility.
PFD Monitor interpretation Inadequate training and guidance to enable personnel to withdraw themselves from heat exposure
Wider context from the report “(1) It is suggested that all Fire and Rescue Services (FRS's) should consider the implementation of measures to reduce the risks associated with the physiological affects of working in a hot environment. In particular consideration should be given to:
Duration of wears under breathing apparatus;
Having regard to all relevant factors including, for example the weather, previous exertions of BA teams and individual circumstances;
Training and guidance for all operational personnel to recognize the effects of heat both on themselves and on their colleagues and the appropriate steps to take upon such recognition, including withdrawal and self withdrawal.
Training and guidance for all operational personnel to have the ability and confidence to ensure the withdrawal of others who may be adversely affected by heat whether by calling a BA emergency or otherwise appropriately.
Training and guidance for all operational personnel to have the ability and confidence to withdraw themselves by whatever means appropriate including activating the ADSU.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chief Fire and Rescue Adviser; that does not assign responsibility.
PFD Monitor interpretation Failure to define the circumstances for inspections under section 7(2)(d) of the Fire and Rescue Services Act 2004
Wider context from the report “(7) It is suggested that all FRSs should undertake a review to consider the circumstances in which inspections should be carried out under section 7(2)(d) of the Fire and Rescue Services Act 2004.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chief Fire and Rescue Adviser; that does not assign responsibility.
PFD Monitor interpretation Loss of communications at operational incidents
Wider context from the report “(2) It is suggested that all FRSs should consider the implementation of measures to reduce the risks associated with the loss of communications at operational incidents . For example, to include safety control measures to ensure BA teams can be withdrawn from the risk area if needed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chief Fire and Rescue Adviser; that does not assign responsibility.
PFD Monitor interpretation Lack of means for responsible persons to verify fire risk assessor competence
Wider context from the report “(9) It is suggested that the Secretary of State for the Home Department considers measures to ensure that:
fire risk assessors are adequately trained and qualified so as to be competent in the role, and
the responsible person has the means to verify the competence of any person holding themselves out to be a fire risk assessor.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chief Fire and Rescue Adviser; that does not assign responsibility.
PFD Monitor interpretation Failure to control breathing-apparatus wear duration according to relevant heat-exposure factors
Wider context from the report “(1) It is suggested that all Fire and Rescue Services (FRS's) should consider the implementation of measures to reduce the risks associated with the physiological affects of working in a hot environment. In particular consideration should be given to:
Duration of wears under breathing apparatus;
Having regard to all relevant factors including, for example the weather, previous exertions of BA teams and individual circumstances;
Training and guidance for all operational personnel to recognize the effects of heat both on themselves and on their colleagues and the appropriate steps to take upon such recognition, including withdrawal and self withdrawal.
Training and guidance for all operational personnel to have the ability and confidence to ensure the withdrawal of others who may be adversely affected by heat whether by calling a BA emergency or otherwise appropriately.
Training and guidance for all operational personnel to have the ability and confidence to withdraw themselves by whatever means appropriate including activating the ADSU.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chief Fire and Rescue Adviser; that does not assign responsibility.
PFD Monitor interpretation Inadequate training and qualification of fire risk assessors
Wider context from the report “(9) It is suggested that the Secretary of State for the Home Department considers measures to ensure that:
fire risk assessors are adequately trained and qualified so as to be competent in the role , and
the responsible person has the means to verify the competence of any person holding themselves out to be a fire risk assessor.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chief Fire and Rescue Adviser; that does not assign responsibility.
PFD Monitor interpretation Failure to test whether national learning is received, understood, actioned and embedded
Wider context from the report “(10) It is understood that there are some 45 Fire and Rescue Services and the findings of the inquest need to be disseminated down to them all. The pressure is upon them to find their own solutions to problems against the backdrop of financial pressures. The Home Office now leads on fire issues and there has been ever increasing decentralisation. Whilst this is not without merit there appear to be difficulties in ensuring that services are meeting expectations and a means of disseminating national learning.
It is suggested that consideration is given to being able to mobilise a national and consistent approach to sharing the learning and testing so that it can be shown to be received, understood, actioned and embedded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chief Fire and Rescue Adviser; that does not assign responsibility.
PFD Monitor interpretation Failure to pass hazard and safety-control information to the incident command team for analytical risk assessment
Wider context from the report “(4) It is suggested that all FRSs should ensure that significant hazards and any safety control measures are the responsibility of the incident commander and should be recorded within each sector, to ensure visibility to all on the fireground, and passed/copied for use by the incident commander/command team to assist on the analytical risk assessment.
” Open source report
12 Feb 2016 Mr. Joseph Sarkozy · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Failure to require positive evidence before concluding that dust on light fittings caused smoke and burning smell View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr. Joseph Sarkozy · 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. Joseph Sarkozy was found dead in his first-floor bedroom after a fire involving discarded smoking materials and bedding. Fire officers had initially attributed smoke and burning smells from the adjoining property to dust on kitchen light fittings, despite the absence of positive evidence. The principal concern was that this conclusion may have delayed recognition of the fire, and the report called for national dissemination of learning about this risk.
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. The report was sent to Chief Fire and Rescue Adviser; that does not assign responsibility.
PFD Monitor interpretation Failure to require positive evidence before concluding that dust on light fittings caused smoke and burning smell
Wider context from the report “(1) The fire officers who attended the premises concluded that the ceiling lights in the kitchen were the most likely source of the smoke and smell which had been detected .
(2) This conclusion was reached as no other source of the smoke and smell was found.
(3) This conclusion was reached notwithstanding there had been no report of any previous problems with the light fittings; no smoke or smell could be detected coming from the light fittings when inspected; the boxes in the room above the light fittings had been dislodged some time before the smoke and smell was detected; and no obvious layer of dust was observed in the room above the light fittings.
(4) The fire service should disseminate nationally the learning from this incident to ensure that other fire officers and fire fighters are aware of the risk of concluding that dust on light fittings can be the cause of smoke and burning smell in the absence of any positive evidence .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations