21 Feb 2022 Sean Ennis · Prevention of Future Deaths report North London
View report summary
Concerns raised 11 Failure to carry out comprehensive fire risk assessments View source Lack of compulsory telecare regulation and minimum standards View source Inadequate fire prevention systems in premises housing vulnerable individuals View source Failure to address identified fire risks from fire risk assessments View source Failure to carry out person-centred risk assessments for sheltered and assisted living residents View source Inadequate fire detection systems in premises housing vulnerable individuals View source Failure to offer telecare to vulnerable people in need View source Lack of Telecare Services Association accreditation View source Failure to regularly review person-centred risk assessments View source Inadequate fire response systems in premises housing vulnerable individuals View source Failure to link telecare to smoke alarms or AFSS View source See 8 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.
×
AI-generated summary
Sean Ennis · 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
Sean Ennis was found in his flat after a fire and died in hospital from the consequences of smoke inhalation. The principal concerns included incomplete fire-risk assessment and inadequate smoke detection and telecare arrangements for a vulnerable resident, including the alarm centre not knowing he was a smoker and not responding when he did not answer calls.
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 London Borough of Brent; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out comprehensive fire risk assessments
Wider context from the report “1. All Responsible Persons should carry out a comprehensive fire risk assessment that details the fire safety provisions that are in the property and where identified ensure that the recommended safety measures have been applied. It is not appropriate to ‘carry over’ identified actions from one fire risk assessment to another, without addressing those risks.
” 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 London Borough of Brent; that does not assign responsibility.
PFD Monitor interpretation Lack of compulsory telecare regulation and minimum standards
Wider context from the report “2. The London Fire Brigade believe that a review should be undertaken with regards to Telecare legislation and regulations. Currently this is an unregulated area and although there are British Standards and industry guidance, these are not compulsory . Legislation should clearly identify a Local Authority’s or responsible person(s) acting on behalf of the Local Authority’s responsibility to assess vulnerable individuals for telecare. This should include a checklist of factors, which should be assessed at regular intervals, with a clearly defined trigger for recommendation for telecare including linking to smoke detection and personal pendants. Legislation should also ensure minimum standards are enforced, practices are standardised and sanctions are available for serious breaches.
” 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 London Borough of Brent; that does not assign responsibility.
PFD Monitor interpretation Inadequate fire prevention systems in premises housing vulnerable individuals
Wider context from the report “7. Premises that knowingly house and provide a service for vulnerable individuals should ensure that their fire prevention , detection and response systems are adequate and appropriate.
” 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 London Borough of Brent; that does not assign responsibility.
PFD Monitor interpretation Failure to address identified fire risks from fire risk assessments
Wider context from the report “1. All Responsible Persons should carry out a comprehensive fire risk assessment that details the fire safety provisions that are in the property and where identified ensure that the recommended safety measures have been applied. It is not appropriate to ‘carry over’ identified actions from one fire risk assessment to another, without addressing those risks .
” 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 London Borough of Brent; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out person-centred risk assessments for sheltered and assisted living residents
Wider context from the report “6. Person Centred Risk Assessments should have been carried out for the residents of Knightlees Court and should be carried out as best practice for residents in Sheltered Accommodation /Assisted Living properties to ensure that needs are met and appropriate measures are in place to safeguard them. PCRAs should be reviewed on a regular basis, no less than every 12 months or when circumstances for the individual change, to ensure that support is appropriate to the individual’s current level of need.
” 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 London Borough of Brent; that does not assign responsibility.
PFD Monitor interpretation Inadequate fire detection systems in premises housing vulnerable individuals
Wider context from the report “7. Premises that knowingly house and provide a service for vulnerable individuals should ensure that their fire prevention, detection and response systems are adequate and appropriate.
” 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 London Borough of Brent; that does not assign responsibility.
PFD Monitor interpretation Failure to offer telecare to vulnerable people in need
Wider context from the report “3. Telecare is not always offered to vulnerable people or if individuals do receive it, is not always linked to smoke alarms or AFSS. Telecare is often at the cost of the individual or Local Authority which may be why a full telecare system is not offered or installed. The Telecare Services Association should consider exploring a sustainable funding source to enable all vulnerable residents in need of telecare to be provided with a full system.
” 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 London Borough of Brent; that does not assign responsibility.
PFD Monitor interpretation Lack of Telecare Services Association accreditation
Wider context from the report “4. Barnet Assist are not Telecare Services Association (TSA) accredited , it is recommended that they become accredited. TSA accreditation ensures that companies agree to providing telecare that meets a set of standards, can receive additional training and encourages consistency in the industry. This should positively impact all service users.
” 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 London Borough of Brent; that does not assign responsibility.
PFD Monitor interpretation Failure to regularly review person-centred risk assessments
Wider context from the report “6. Person Centred Risk Assessments should have been carried out for the residents of Knightlees Court and should be carried out as best practice for residents in Sheltered Accommodation /Assisted Living properties to ensure that needs are met and appropriate measures are in place to safeguard them. PCRAs should be reviewed on a regular basis, no less than every 12 months or when circumstances for the individual change , to ensure that support is appropriate to the individual’s current level of need.
” 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 London Borough of Brent; that does not assign responsibility.
PFD Monitor interpretation Inadequate fire response systems in premises housing vulnerable individuals
Wider context from the report “7. Premises that knowingly house and provide a service for vulnerable individuals should ensure that their fire prevention, detection and response systems are adequate and appropriate .
” 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 London Borough of Brent; that does not assign responsibility.
PFD Monitor interpretation Failure to link telecare to smoke alarms or AFSS
Wider context from the report “3. Telecare is not always offered to vulnerable people or if individuals do receive it, is not always linked to smoke alarms or AFSS . Telecare is often at the cost of the individual or Local Authority which may be why a full telecare system is not offered or installed. The Telecare Services Association should consider exploring a sustainable funding source to enable all vulnerable residents in need of telecare to be provided with a full system.
” 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