19 Jul 2023 Sylvia Pollitt · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Failure to capture and monitor referral outcomes View source Lack of an audit system for non-escalation following referrals View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Hold weekly contractor meetings, reconcile work-in-progress reports with internal records, and review every repair to prevent unauthorised abortion without escalation.
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Action
Automatically follow up incomplete or requested-aborted repairs and escalate unsuccessful resident contact for an in-person welfare check.
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Action
Review all gas repairs closed outside the agreed service level without reference back, tracing records and identifying closure reasons.
View source
Action
Record relevant calls centrally and track every repair through the internal housing management system to maintain an auditable trail.
View source
Action
Align property services and building compliance policies and processes, including gas safety and contractor management.
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AI-generated summary
Sylvia Pollitt · 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
Sylvia Pollitt, an elderly resident, raised a concern about her boiler, but the subcontractor could not contact her and the situation was not escalated. She was found at home on 1 December 2022 and the post-mortem found that she had died from complications of hypothermia. The inquest identified that welfare checks were not carried out and that the Housing Association lacked systems to monitor non-escalation and referral outcomes.
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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 London & Quadrant Housing Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to capture and monitor referral outcomes
Wider context from the report “The inquest heard evidence that under the SLA between the Housing Association and Liberty if there is non-contact following a referral then this should be escalated back to the Housing Association so that they can carry out welfare checks and assess the position further. Carrying out of welfare checks for vulnerable adults ensures that they are safe and well. That did not happen in Mrs Pollitt’s case. The evidence before the inquest was that the Housing Association had:
1. No audit system which enabled it to know if this issue of non-escalation by Liberty was a one off or a frequent issue. They had only become aware of the non-contact in this instance following Sylvia Pollitt’s death.
2. No system where they captured/monitored the outcome of each referral to their subcontractor e.g. non-contact; successful attendance.
” 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 & Quadrant Housing Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an audit system for non-escalation following referrals
Wider context from the report “The inquest heard evidence that under the SLA between the Housing Association and Liberty if there is non-contact following a referral then this should be escalated back to the Housing Association so that they can carry out welfare checks and assess the position further. Carrying out of welfare checks for vulnerable adults ensures that they are safe and well. That did not happen in Mrs Pollitt’s case. The evidence before the inquest was that the Housing Association had:
1. No audit system which enabled it to know if this issue of non-escalation by Liberty was a one off or a frequent issue. They had only become aware of the non-contact in this instance following Sylvia Pollitt’s death.
2. No system where they captured/monitored the outcome of each referral to their subcontractor e.g. non-contact; successful attendance.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold weekly contractor meetings, reconcile work-in-progress reports with internal records, and review every repair to prevent unauthorised abortion without escalation.
Verbatim wording from the response “That notwithstanding, we have subsequently instituted weekly meetings with Liberty to review every single job raised to trace all those in progress, overdue, completed and requested to be aborted. A full Work In Progress (WIP) report is produced by Liberty which is reconciled against the list held by L&Q and is reviewed by the Gas Compliance Manager weekly to ensure every single repair is accounted for. No jobs are permitted or are possible to be aborted directly by Liberty without reference back to L&Q and the report records all reasons for no access and dates of escalation back to L&Q.” Source location Response from L&Q
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Automatically follow up incomplete or requested-aborted repairs and escalate unsuccessful resident contact for an in-person welfare check.
Verbatim wording from the response “All cases of incomplete and requested aborted jobs are automatically followed up by the L&Q gas team to make contact with the resident and if this is unsuccessful, they are immediately passed to the housing management team to make an in-person welfare check.” Source location Response from L&Q
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review all gas repairs closed outside the agreed service level without reference back, tracing records and identifying closure reasons.
Verbatim wording from the response “As soon as we were aware of the incident and the inquest, we immediately reviewed every other gas repair request which had been closed by Liberty outside of the agreed SLA and without reference back to L&Q.” Source location Response from L&Q
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record relevant calls centrally and track every repair through the internal housing management system to maintain an auditable trail.
Verbatim wording from the response “Following the inquest and prior to your formal recommendations contained within this Regulation 28 Prevention of Future Deaths report, we had immediately put in place additional processes and checks. This included aligning the process of the former THT with that of L&Q where all calls of this nature are recorded by and within the central call centre prior to being passed to contractors, ensuring that a comprehensive record of all repairs is tracked and managed through our internal housing management system. The previous THT process was to transfer the resident call directly to the contractor, in this incident Liberty.” Source location Response from L&Q
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Align property services and building compliance policies and processes, including gas safety and contractor management.
Verbatim wording from the response “To provide some context, we would like to highlight that Mrs Pollitt’s death occurred during a transition phase for L&Q and the previous Trafford Housing Trust (“THT”), this was as the two entities were integrating, a process which completed on 31st March 2023. The processes in place at the time were those of THT. This is not intended to avoid any ownership of the incident on our part, it is to provide the context. We have since aligned the L&Q property services and building compliance policies and processes, which includes the gas safety and contractor management processes. This shall, as we will hopefully demonstrate, now provide greater control and will prevent future deaths from these incidents occurring.” Source location Response from L&Q
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations