3 Oct 2018 Brian Alban Frost · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 4 Failure to undertake health and safety or risk assessments during welfare visits View source Reliance on residents or informal third parties to identify hazards and request accommodation repairs View source Lack of independent assessment for health and safety risks in grace and favour accommodation View source Unsafe loose and displaced flooring creating a trip hazard in occupied accommodation View source See 1 more 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
Brian Alban Frost · 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
Brian Alban Frost, a 92-year-old retired Roman Catholic priest who lived alone, died after an unwitnessed fall at home on 30 June 2018, sustaining severe head injuries. The report raised concerns about loose kitchen floor tiles presenting a trip hazard and about the inadequacy of welfare checks and health-and-safety risk assessments for retired clergy living in diocesan properties.
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 East Coast Community Healthcare C.I.C.; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake health and safety or risk assessments during welfare visits
Wider context from the report “5. It was heard in evidence that the diocese had a system of visits in place from the Clergy Welfare Officer and, if the retired priest was subject to a ‘covenant of care’ a Safeguarding Coordinator. Details of visits to Canon Frost’s home were recorded as taking place in October 2010, December 2010, January 2011, July 2011, May 2012, January 2013, April 2014, August 2014, July 2016 and October 2017.
6. In reports compiled in relation to these visits no mention is made of any health and safety or risk assessment activity being undertaken.
7. A note from the October 2017 visit (11 months prior to Canon Frost’s death) provides details of a recent fall in which Canon Frost fractured his hip, the fact he now used a walking frame and that his bedroom had been moved down stairs (following a visit from the local NHS Community Health Team). The property manager offered Canon Frost a visit from the Clergy Welfare Coordinator but this was declined.
8. Despite identifying major factors regarding Canon Frost’s mobility and increasing frailty, again no mention is made of any health and safety or risk assessment activity being undertaken.
9. Giving the nature of the residents of these properties there is a degree of certainty that other ‘grace and favour’ residents will lose (or have already lost) the physical ability or the mental capacity to maintain their accommodation in a safe condition. On the evidence heard the system of welfare checks was not sufficiently robust and there was no independent assessment for health and safety risks. It was apparent that the current system required the resident themselves, a family member or some other third party to raise such concerns when the fabric of the building is deteriorating. The resident themselves would then need to request for the work to be undertaken.
10. Dependant on the personal circumstance of each retired member of the clergy this system appears flawed, as it relies solely on the resident retaining the mental capacity and/or the physical ability to identify that a hazard exists and then make their own request for repairs. Without doubt, the welfare system currently in place failed to identify and remedy the fact that an obvious and serious trip hazard risk was present in Canon Frost's home.
” 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 East Coast Community Healthcare C.I.C.; that does not assign responsibility.
PFD Monitor interpretation Reliance on residents or informal third parties to identify hazards and request accommodation repairs
Wider context from the report “5. It was heard in evidence that the diocese had a system of visits in place from the Clergy Welfare Officer and, if the retired priest was subject to a ‘covenant of care’ a Safeguarding Coordinator. Details of visits to Canon Frost’s home were recorded as taking place in October 2010, December 2010, January 2011, July 2011, May 2012, January 2013, April 2014, August 2014, July 2016 and October 2017.
6. In reports compiled in relation to these visits no mention is made of any health and safety or risk assessment activity being undertaken.
7. A note from the October 2017 visit (11 months prior to Canon Frost’s death) provides details of a recent fall in which Canon Frost fractured his hip, the fact he now used a walking frame and that his bedroom had been moved down stairs (following a visit from the local NHS Community Health Team). The property manager offered Canon Frost a visit from the Clergy Welfare Coordinator but this was declined.
8. Despite identifying major factors regarding Canon Frost’s mobility and increasing frailty, again no mention is made of any health and safety or risk assessment activity being undertaken.
9. Giving the nature of the residents of these properties there is a degree of certainty that other ‘grace and favour’ residents will lose (or have already lost) the physical ability or the mental capacity to maintain their accommodation in a safe condition. On the evidence heard the system of welfare checks was not sufficiently robust and there was no independent assessment for health and safety risks. It was apparent that the current system required the resident themselves, a family member or some other third party to raise such concerns when the fabric of the building is deteriorating . The resident themselves would then need to request for the work to be undertaken .
10. Dependant on the personal circumstance of each retired member of the clergy this system appears flawed, as it relies solely on the resident retaining the mental capacity and/or the physical ability to identify that a hazard exists and then make their own request for repairs . Without doubt, the welfare system currently in place failed to identify and remedy the fact that an obvious and serious trip hazard risk was present in Canon Frost's home.
” 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 East Coast Community Healthcare C.I.C.; that does not assign responsibility.
PFD Monitor interpretation Lack of independent assessment for health and safety risks in grace and favour accommodation
Wider context from the report “5. It was heard in evidence that the diocese had a system of visits in place from the Clergy Welfare Officer and, if the retired priest was subject to a ‘covenant of care’ a Safeguarding Coordinator. Details of visits to Canon Frost’s home were recorded as taking place in October 2010, December 2010, January 2011, July 2011, May 2012, January 2013, April 2014, August 2014, July 2016 and October 2017.
6. In reports compiled in relation to these visits no mention is made of any health and safety or risk assessment activity being undertaken.
7. A note from the October 2017 visit (11 months prior to Canon Frost’s death) provides details of a recent fall in which Canon Frost fractured his hip, the fact he now used a walking frame and that his bedroom had been moved down stairs (following a visit from the local NHS Community Health Team). The property manager offered Canon Frost a visit from the Clergy Welfare Coordinator but this was declined.
8. Despite identifying major factors regarding Canon Frost’s mobility and increasing frailty, again no mention is made of any health and safety or risk assessment activity being undertaken.
9. Giving the nature of the residents of these properties there is a degree of certainty that other ‘grace and favour’ residents will lose (or have already lost) the physical ability or the mental capacity to maintain their accommodation in a safe condition. On the evidence heard the system of welfare checks was not sufficiently robust and there was no independent assessment for health and safety risks . It was apparent that the current system required the resident themselves, a family member or some other third party to raise such concerns when the fabric of the building is deteriorating. The resident themselves would then need to request for the work to be undertaken.
10. Dependant on the personal circumstance of each retired member of the clergy this system appears flawed, as it relies solely on the resident retaining the mental capacity and/or the physical ability to identify that a hazard exists and then make their own request for repairs. Without doubt, the welfare system currently in place failed to identify and remedy the fact that an obvious and serious trip hazard risk was present in Canon Frost's home.
” 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 East Coast Community Healthcare C.I.C.; that does not assign responsibility.
PFD Monitor interpretation Unsafe loose and displaced flooring creating a trip hazard in occupied accommodation
Wider context from the report “2. Photographic evidence produced during the inquest of Canon Frost clearly demonstrates that the floor tiles in his kitchen had become loose and were no longer fastened to the floor . One of the floor tiles is completely out of position and the others appear to be loose with large gaps between the tiles themselves . In his witness statement ████████ commented “the flooring where Canon Frost would have fallen was very loose and could have been a trip hazard for Canon Frost .”
3. Considering his frailty, the fact he lived alone and the medical conditions suffered by Canon Frost, on the available evidence this flooring was clearly not safe by any measure . In evidence it was heard that the flooring is sufficiently porous that it will need to be replaced prior to the re-occupation/sale of the property.
” Open source report
3 Oct 2018 Brian Alban Frost · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 4 Reliance on residents or third parties to identify hazards and request repairs View source Lack of independent health and safety assessment in welfare checks View source Failure to undertake health and safety or risk assessments during welfare visits View source Unsafe loose kitchen flooring creating a trip hazard View source See 1 more concern
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Brian Alban Frost · 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
Brian Alban Frost died after an unwitnessed fall at home in which he sustained severe head injuries. The report identifies loose kitchen floor tiles as a serious trip hazard and raises concerns that welfare checks for retired priests living in diocesan properties did not include independent health and safety or risk assessments, allowing hazards to remain unidentified and unrepaired.
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 East Coast Community Healthcare C.I.C.; that does not assign responsibility.
PFD Monitor interpretation Reliance on residents or third parties to identify hazards and request repairs
Wider context from the report “9. Giving the nature of the residents of these properties there is a degree of certainty that other ‘grace and favour’ residents who lose (or have already lost) the physical ability or the mental capacity to maintain their accommodation in a safe condition. On the evidence heard the system of welfare checks was not sufficiently robust and there was no independent assessment for health and safety risks. It was apparent that the current system required the resident themselves, a family member or some other third party to raise such concerns when the fabric of the building is deteriorating . The resident themselves would then need to request for the work to be undertaken .
10. Dependant on the personal circumstance of each retired member of the clergy this system appears flawed, as it relies solely on the resident retaining the mental capacity and/or the physical ability to identify that a hazard exists and then make their own request for repairs . Without doubt, the welfare system currently in place failed to identify and remedy the fact that an obvious and serious trip hazard risk was present in Canon Frost’s home.
11. Given that this is the case I am concerned that other residents of ‘grace and favour’ homes provided by the Bishop of each dioceses, may now also be living in premises that may no longer be considered safe for their occupation.
” 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 East Coast Community Healthcare C.I.C.; that does not assign responsibility.
PFD Monitor interpretation Lack of independent health and safety assessment in welfare checks
Wider context from the report “9. Giving the nature of the residents of these properties there is a degree of certainty that other ‘grace and favour’ residents who lose (or have already lost) the physical ability or the mental capacity to maintain their accommodation in a safe condition. On the evidence heard the system of welfare checks was not sufficiently robust and there was no independent assessment for health and safety risks . It was apparent that the current system required the resident themselves, a family member or some other third party to raise such concerns when the fabric of the building is deteriorating. The resident themselves would then need to request for the work to be undertaken.
10. Dependant on the personal circumstance of each retired member of the clergy this system appears flawed, as it relies solely on the resident retaining the mental capacity and/or the physical ability to identify that a hazard exists and then make their own request for repairs. Without doubt, the welfare system currently in place failed to identify and remedy the fact that an obvious and serious trip hazard risk was present in Canon Frost’s home.
11. Given that this is the case I am concerned that other residents of ‘grace and favour’ homes provided by the Bishop of each dioceses, may now also be living in premises that may no longer be considered safe for their occupation.
” 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 East Coast Community Healthcare C.I.C.; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake health and safety or risk assessments during welfare visits
Wider context from the report “5. It was heard in evidence that the diocese had a system of visits in place from the Clergy Welfare Officer, and if the retired priest was subject to ‘covenant of care’ a Safeguarding Coordinator. Details of visits to Canon Frost's home were recorded as taking place in October 2010, December 2010, January 2011, July 2011, May 2012, January 2013, April 2014, August 2014, July 2016 and October 2017.
6. In reports compiled in relation to these visits no mention is made of any health and safety or risk assessment activity being undertaken.
7. A note from the October 2017 visit (11 months prior to Canon Frost’s death) provides details of a recent fall in which Canon Frost fractured his hip, the fact he now used a walking frame and that his bedroom had been moved down stairs (following a visit from the local NHS Community Health Team). The property manager offered Canon Frost a visit from the Clergy Welfare Coordinator but this was declined.
8. Despite identifying major factors regarding Canon Frost’s mobility and increasing frailty, again no mention is made of any health and safety or risk assessment activity being undertaken .
” 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 East Coast Community Healthcare C.I.C.; that does not assign responsibility.
PFD Monitor interpretation Unsafe loose kitchen flooring creating a trip hazard
Wider context from the report “2. Photographic evidence produced during the inquest of Canon Frost clearly demonstrates that the floor tiles in his kitchen had become loose and were no longer fastened to the floor . One of the floor tiles is completely out of position and the others appear to be loose with large gaps between the tiles themselves . In his witness statement ████████ commented “the flooring where Canon Frost would have fallen was very loose and could have been a trip hazard for Canon Frost.”
3. Considering his frailty, the fact he lived alone and the medical conditions suffered by Canon Frost, on the available evidence this flooring was clearly not safe by any measure . In evidence it was heard that the flooring is sufficiently poor that it will need to be replaced prior to the re-occupation/sale of the property.
” 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