18 Oct 2013 ELIZABETH AURORA KERR · Prevention of Future Deaths report Manchester City
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Concerns raised 14 Unavailability of carbon monoxide detection equipment on Fire and Rescue Service frontline appliances View source Absence of a statutory Fire and Rescue Service role in carbon monoxide safety, regulation and enforcement View source Lack of suitable training in the operation of carbon monoxide detection equipment View source Lack of clear oversight of gas-supplier steps to raise awareness of danger View source Lack of clear gas-supplier criteria for identifying vulnerable and priority customers View source Failure to identify incomplete flue piping during routine inspections View source Lack of understanding and detailed guidance on the movement of carbon monoxide within buildings View source Lack of established monitoring of offers and uptake of free annual gas safety checks View source Lack of a duty to warn other occupants to install carbon monoxide alarms View source Lack of regulatory coverage for ongoing maintenance and inspection of existing solid fuel appliances View source Lack of a duty to allow recognised engineers to inspect boilers in multi-occupancy buildings View source Lack of required audit trails of fuel-supplier carbon monoxide safety steps View source Lack of HSE guidance to landlords and letting agents on independent validation of gas and other fuel safety equipment in rented property View source Lack of required specific carbon monoxide safety information from fuel suppliers View source See 11 more concerns
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ELIZABETH AURORA KERR · 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
Elizabeth Aurora Kerr died after carbon monoxide from a malfunctioning basement boiler entered the residential flat where she lived, and she was found unconscious several hours after the Fire Service had attended the building. The report identified concerns about the movement and detection of carbon monoxide in buildings, the absence and use of carbon monoxide alarms and gas safety controls, and Fire and Rescue Service equipment, guidance and responses.
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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 Department of Energy & Climate Change; that does not assign responsibility.
PFD Monitor interpretation Unavailability of carbon monoxide detection equipment on Fire and Rescue Service frontline appliances
Wider context from the report “7. The use and availability of CGI meters by Fire and Rescue Services and having suitable training in their operation as well as the use of personal protective equipment CO alarms.
GMFRS did some research in the use of such equipment by all Fire and Rescue Services. Please see the attached. It is suggested that if all Fire and Rescue Services carried such equipment on front line appliances and used them on both emergency responses and preventative work that would reduce the risk of death to Fire Fighters and the public.
” 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 Department of Energy & Climate Change; that does not assign responsibility.
PFD Monitor interpretation Absence of a statutory Fire and Rescue Service role in carbon monoxide safety, regulation and enforcement
Wider context from the report “3. The Role of Fire and Rescue Services in Carbon Monoxide Safety:
The Fire and Rescue Services currently have no statutory role in Carbon Monoxide safety, regulation and enforcement. This could be reviewed and considered by the Department for Communities and Local Government. It is appreciated that this is far from straight forward and wider issues would need to be taken into account. For example Fire and Rescue Services have no statutory role in other gases or substances which can cause death. This may require a more detailed analysis and assessment of issues and complications which may then come to light. In the absence of a statutory role, and possibly through the Chief Fire Officers Association “Blue Watch” initiative, Fire and Rescue Services could be encouraged to voluntarily engage in local and national Carbon Monoxide campaigns. Such campaigns may benefit from closer working at a local level with relevant CO charities and at a national level between the Gas Safety Trust, the Gas Safe Charity and the Chief Fire Officers Association.
” 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 Department of Energy & Climate Change; that does not assign responsibility.
PFD Monitor interpretation Lack of suitable training in the operation of carbon monoxide detection equipment
Wider context from the report “7. The use and availability of CGI meters by Fire and Rescue Services and having suitable training in their operation as well as the use of personal protective equipment CO alarms.
GMFRS did some research in the use of such equipment by all Fire and Rescue Services. Please see the attached. It is suggested that if all Fire and Rescue Services carried such equipment on front line appliances and used them on both emergency responses and preventative work that would reduce the risk of death to Fire Fighters and the public.
” 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 Department of Energy & Climate Change; that does not assign responsibility.
PFD Monitor interpretation Lack of clear oversight of gas-supplier steps to raise awareness of danger
Wider context from the report “4. Piped Gas Suppliers:
It is understood that there are specific conditions of a licence to supply gas as summarised below. It is not clear how gas suppliers define and determine who is a ”vulnerable and priority” customer and how it is established that they have been offered a free annual gas safety check, and have taken advantage (or not) of such an offer ? Nor who actually checks what steps a gas supplier takes in practice to raise the awareness of danger and who judges the reasonability of the steps?
” 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 Department of Energy & Climate Change; that does not assign responsibility.
PFD Monitor interpretation Lack of clear gas-supplier criteria for identifying vulnerable and priority customers
Wider context from the report “4. Piped Gas Suppliers:
It is understood that there are specific conditions of a licence to supply gas as summarised below. It is not clear how gas suppliers define and determine who is a ”vulnerable and priority” customer and how it is established that they have been offered a free annual gas safety check, and have taken advantage (or not) of such an offer ? Nor who actually checks what steps a gas supplier takes in practice to raise the awareness of danger and who judges the reasonability of the steps?
” 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 Department of Energy & Climate Change; that does not assign responsibility.
PFD Monitor interpretation Failure to identify incomplete flue piping during routine inspections
Wider context from the report “8. The Chief Fire Officers Association “Blue Watch Initiative”
This is a voluntary initiative to be encouraged and supported. It offers an independent safety validation service for landlords and letting agents.
http://www.bluewatch.co.uk/. The investigation established that incomplete flue piping had not been identified on routine inspection visits despite the regulatory regime created by The Gas Safety (Installation and Use ) Regulations 1988. At present there is no duty imposed on the owner of a boiler or a gas supplier ( who makes a profit from the supply ) that in the case of a multi occupancy building to allow the other occupants , through recognised engineers , to inspect the boiler and be warned to install CO alarms.
” 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 Department of Energy & Climate Change; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding and detailed guidance on the movement of carbon monoxide within buildings
Wider context from the report “2. Guidance on the potential movement of CO within a building:
There appears to be a lack of understanding and detailed guidance on the potential movement of CO within a building from its original source and how it can penetrate and move within it. The HSE could provide more information on its web site and provide specific guidance or warnings. There is no HSE guidance to landlords and letting agents as to what independent validation has taken place of the gas and other fuel safety equipment provided in rented property may be appropriate. Such information could also be disseminated to and within all Fire and Rescue Services.
” 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 Department of Energy & Climate Change; that does not assign responsibility.
PFD Monitor interpretation Lack of established monitoring of offers and uptake of free annual gas safety checks
Wider context from the report “4. Piped Gas Suppliers:
It is understood that there are specific conditions of a licence to supply gas as summarised below. It is not clear how gas suppliers define and determine who is a ”vulnerable and priority” customer and how it is established that they have been offered a free annual gas safety check, and have taken advantage (or not) of such an offer ? Nor who actually checks what steps a gas supplier takes in practice to raise the awareness of danger and who judges the reasonability of the steps?
” 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 Department of Energy & Climate Change; that does not assign responsibility.
PFD Monitor interpretation Lack of a duty to warn other occupants to install carbon monoxide alarms
Wider context from the report “8. The Chief Fire Officers Association “Blue Watch Initiative”
This is a voluntary initiative to be encouraged and supported. It offers an independent safety validation service for landlords and letting agents.
http://www.bluewatch.co.uk/. The investigation established that incomplete flue piping had not been identified on routine inspection visits despite the regulatory regime created by The Gas Safety (Installation and Use ) Regulations 1988. At present there is no duty imposed on the owner of a boiler or a gas supplier ( who makes a profit from the supply ) that in the case of a multi occupancy building to allow the other occupants , through recognised engineers , to inspect the boiler and be warned to install CO alarms.
” 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 Department of Energy & Climate Change; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory coverage for ongoing maintenance and inspection of existing solid fuel appliances
Wider context from the report “6. The installation , use , maintenance and correct positioning of fixed hard wired or battery operated CO alarms.
From October 1st 2010 Building Regulations Approved Document J “Combustion appliances and fuel storage systems” sets out a number of legal requirements in England and Wales. For the first time carbon monoxide (CO) alarms were made mandatory “where a new or replacement fixed solid fuel appliance is installed in a dwelling, a CO alarm should be provided in the room where the appliance is located.” However Building Regulations only concern the processes used during the ‘building’ or ‘installation’ phases, of a solid fuel appliance and do not have any power to talk about on-going maintenance processes or the inspection of existing appliances.
” 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 Department of Energy & Climate Change; that does not assign responsibility.
PFD Monitor interpretation Lack of a duty to allow recognised engineers to inspect boilers in multi-occupancy buildings
Wider context from the report “8. The Chief Fire Officers Association “Blue Watch Initiative”
This is a voluntary initiative to be encouraged and supported. It offers an independent safety validation service for landlords and letting agents.
http://www.bluewatch.co.uk/. The investigation established that incomplete flue piping had not been identified on routine inspection visits despite the regulatory regime created by The Gas Safety (Installation and Use ) Regulations 1988. At present there is no duty imposed on the owner of a boiler or a gas supplier ( who makes a profit from the supply ) that in the case of a multi occupancy building to allow the other occupants , through recognised engineers , to inspect the boiler and be warned to install CO alarms.
” 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 Department of Energy & Climate Change; that does not assign responsibility.
PFD Monitor interpretation Lack of required audit trails of fuel-supplier carbon monoxide safety steps
Wider context from the report “5. Enforcement and Information:
There is no requirement that in the case of a carbon monoxide death, a clear audit trail is available of the steps taken by the relevant fuel supplier to ensure the specific customer in question was aware of the dangers of carbon monoxide poisoning and the benefits of fitting an audible alarm. At the moment there is no specific information that fuel suppliers are required to give.
” 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 Department of Energy & Climate Change; that does not assign responsibility.
PFD Monitor interpretation Lack of HSE guidance to landlords and letting agents on independent validation of gas and other fuel safety equipment in rented property
Wider context from the report “2. Guidance on the potential movement of CO within a building:
There appears to be a lack of understanding and detailed guidance on the potential movement of CO within a building from its original source and how it can penetrate and move within it. The HSE could provide more information on its web site and provide specific guidance or warnings. There is no HSE guidance to landlords and letting agents as to what independent validation has taken place of the gas and other fuel safety equipment provided in rented property may be appropriate. Such information could also be disseminated to and within all Fire and Rescue Services.
” 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 Department of Energy & Climate Change; that does not assign responsibility.
PFD Monitor interpretation Lack of required specific carbon monoxide safety information from fuel suppliers
Wider context from the report “5. Enforcement and Information:
There is no requirement that in the case of a carbon monoxide death, a clear audit trail is available of the steps taken by the relevant fuel supplier to ensure the specific customer in question was aware of the dangers of carbon monoxide poisoning and the benefits of fitting an audible alarm. At the moment there is no specific information that fuel suppliers are required to give.
” 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