11 Sep 2017 Mr Brian MacLean · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 7 Failure of Social Services to proactively pursue referrals and understand fire risks through joined-up interagency working View source Failure to identify people potentially at risk of fire in their premises View source Lack of a GPHA process to automatically consider fire risks and prevention View source Lack of automatic water suppression systems for blocks of flats and individuals at high risk View source Failure to refer people at risk of fire to GMFRS View source Failure of GPHA to make referrals to GMFRS for safe and well visits View source Lack of appropriate smoke alarms and assistive technology View source See 4 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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. The report was sent to Great Places Housing Association; that does not assign responsibility.
PFD Monitor interpretation Failure of Social Services to proactively pursue referrals and understand fire risks through joined-up interagency working
Wider context from the report “1. That Social Services did not take a more proactive role in pursuing any referral and understanding the risks presented by the deceased . This requires joined up thinking and working with GPs, the NHS locally, the housing provider and finally GMFRS .
” 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 Great Places Housing Association; that does not assign responsibility.
PFD Monitor interpretation Failure to identify people potentially at risk of fire in their premises
Wider context from the report “2. There was no identification of the deceased as being potentially at risk of a fire in his premises and no referral to GMFRS.
” 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 Great Places Housing Association; that does not assign responsibility.
PFD Monitor interpretation Lack of a GPHA process to automatically consider fire risks and prevention
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.
” 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 Great Places Housing Association; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic water suppression systems for blocks of flats and individuals at high risk
Wider context from the report “4. It is clear that GPHA did not have an automatic water suppression system (sprinklers) that could be fitted to properties which comprise blocks of flats and or for individuals at high risk . In addition appropriate smoke alarms and other assistive technology could have been installed.
5. The recipients of this report would be well advised to read and digest the detailed GMFRS Fire Investigation Report and its recommendations which are wholly endorsed by the court.
” 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 Great Places Housing Association; that does not assign responsibility.
PFD Monitor interpretation Failure to refer people at risk of fire to GMFRS
Wider context from the report “2. There was no identification of the deceased as being potentially at risk of a fire in his premises and no referral to GMFRS .
” 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 Great Places Housing Association; that does not assign responsibility.
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 .
” 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 Great Places Housing Association; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate smoke alarms and assistive technology
Wider context from the report “4. It is clear that GPHA did not have an automatic water suppression system (sprinklers) that could be fitted to properties which comprise blocks of flats and or for individuals at high risk. In addition appropriate smoke alarms and other assistive technology could have been installed .
5. The recipients of this report would be well advised to read and digest the detailed GMFRS Fire Investigation Report and its recommendations which are wholly endorsed by the court.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations