19 Apr 2026 Paul HUTCHINSON · Prevention of Future Deaths report West London
View report summary
Concerns raised 5 Failure to standardise staff training on evacuation, alarm, telecare and fire suppression procedures View source Failure of Fire Risk Assessments to account for vulnerable residents at special risk View source Lack of timescales for regular reviews of PCFRAs and personal emergency evacuation arrangements View source Lack of specific requirements for PCFRAs and personal emergency evacuation plans with agreed formats and risk factors View source Lack of specific requirements for emergency equipment and staff training View source See 2 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
Paul HUTCHINSON · 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
Paul HUTCHINSON died of burns after setting himself alight while smoking in his Extra Care Sheltered Accommodation on 21 January 2025. The report raised concerns about the lack of specific requirements for individual fire risk and evacuation assessments, non-standardised staff training, and whether fire risk assessments adequately considered vulnerable residents who may be unable to self-evacuate.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure to standardise staff training on evacuation, alarm, telecare and fire suppression procedures
Wider context from the report “2. Staff training is not standardised for ECSA (or sheltered accommodation more generally) and may not include, for example, evacuation strategy, emergency evacuation plans, the use of telecare/fire alarm system and fire suppression systems .
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure of Fire Risk Assessments to account for vulnerable residents at special risk
Wider context from the report “3. Fire Risk Assessments for premises providing ECSA and sheltered accommodation more generally may not contemplate vulnerable residents as forming 'any group of persons identified...as being especially at risk' (see article 9(7)(b) of the 2005 Regulations). Vulnerable residents may be at special risk because of (for example) smoking or cooking practices and may have a compromised ability to self-evacuate. The concern is that Fire Risk Assessments do not take this into account .
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of timescales for regular reviews of PCFRAs and personal emergency evacuation arrangements
Wider context from the report “1. The Regulatory Reform (Fire Safety) Order 2005 and the Fire Safety (Residential Evacuation Plans) Regulations 2025 do not appear to apply to the individual flats in ECSA because they are private dwellings. The concern is that there is no specific requirement for a PCFRA (or a personal emergency evacuation through the PCFRA) with an agreed format and risk factors, a requirement for emergency equipment and staff training and a timescale for regular reviews (including where the individual circumstances of a person in care change) . This concern may apply to others in formal residential care.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of specific requirements for PCFRAs and personal emergency evacuation plans with agreed formats and risk factors
Wider context from the report “1. The Regulatory Reform (Fire Safety) Order 2005 and the Fire Safety (Residential Evacuation Plans) Regulations 2025 do not appear to apply to the individual flats in ECSA because they are private dwellings. The concern is that there is no specific requirement for a PCFRA (or a personal emergency evacuation through the PCFRA) with an agreed format and risk factors , a requirement for emergency equipment and staff training and a timescale for regular reviews (including where the individual circumstances of a person in care change). This concern may apply to others in formal residential care.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of specific requirements for emergency equipment and staff training
Wider context from the report “1. The Regulatory Reform (Fire Safety) Order 2005 and the Fire Safety (Residential Evacuation Plans) Regulations 2025 do not appear to apply to the individual flats in ECSA because they are private dwellings. The concern is that there is no specific requirement for a PCFRA (or a personal emergency evacuation through the PCFRA) with an agreed format and risk factors, a requirement for emergency equipment and staff training and a timescale for regular reviews (including where the individual circumstances of a person in care change). This concern may apply to others in formal residential care.
” Open source report
7 Apr 2026 Joshua Christopher Edward PERRY · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2 Lack of clarity on the starting point for measuring barrier height when an obstruction is used as guarding View source Failure of guarding guidance to address horizontal-railing climbing risks for adults and children over five years View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joshua Christopher Edward PERRY · 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
Joshua Perry died on 14 March 2025 after falling from the nineteenth floor of a multi-storey car park and suffering multiple injuries. Ketamine had been consumed before his death, and the inquest could not establish whether he intended to take his own life. The principal concerns were an unresolved conflict between building regulations and BSI standards about measuring barrier heights, and guidance that addresses horizontal railings in relation to young children but not adults or older children.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity on the starting point for measuring barrier height when an obstruction is used as guarding
Wider context from the report “During the course of the inquest it came to my attention that there is a conflict between The Building Regulations 2010, Guidance: Approved Document K and BSI Standards, barriers in and about buildings, Code of Practice , which requires its resolution and may prevent future deaths.
Document K at K2 paragraph 3.2 outlines that guarding must be at a minimum height and that any wall, parapet, balustrade or similar obstruction can be used as guarding. The British Standards, Code of Practice indicates that barriers installed on parapet walls should be measured from the top of the parapet and not at walk level. It is not clear from the guidance and standards whether the starting point of the barrier height is to be taken from when a wall, parapet, balustrade or similar obstruction is used as guarding.
Document K at K2 paragraph 3.3 outlines that the use of horizontal railings should be avoided to prevent children under the age of 5 years readily being able to climb the guarding, there is no mention of this also being applicable to adults and children over the age of 5 years.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure of guarding guidance to address horizontal-railing climbing risks for adults and children over five years
Wider context from the report “During the course of the inquest it came to my attention that there is a conflict between The Building Regulations 2010, Guidance: Approved Document K and BSI Standards, barriers in and about buildings, Code of Practice, which requires its resolution and may prevent future deaths.
Document K at K2 paragraph 3.2 outlines that guarding must be at a minimum height and that any wall, parapet, balustrade or similar obstruction can be used as guarding. The British Standards, Code of Practice indicates that barriers installed on parapet walls should be measured from the top of the parapet and not at walk level. It is not clear from the guidance and standards whether the starting point of the barrier height is to be taken from when a wall, parapet, balustrade or similar obstruction is used as guarding.
Document K at K2 paragraph 3.3 outlines that the use of horizontal railings should be avoided to prevent children under the age of 5 years readily being able to climb the guarding , there is no mention of this also being applicable to adults and children over the age of 5 years .
” Open source report
×
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 Conduct a call for evidence on Approved Document K to gather views and consider potential strengthening or clarification of guarding and fall-prevention guidance.
Verbatim wording from the response “The Ministry for Housing, Communities and Local Government (MHCLG) intends to consider the issues raised through a forthcoming call for evidence on ADK where we will be seeking views to help us understand which areas may need strengthening, greater clarity or further research. This” Source location Response from MHCLG
Open published response
28 Dec 2025 Mohamed Abdisamad · Prevention of Future Deaths report West London
View report summary
Concerns raised 6 Failure to obtain consent before NTMC View source Lack of infection control requirements for NTMC View source Lack of external accreditation and registration for NTMC practitioners View source Lack of record-keeping requirements for NTMC View source Lack of training and continuing professional development requirements for NTMC practitioners View source Lack of aftercare requirements for NTMC View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mohamed Abdisamad · 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
Mohamed Abdisamad underwent a non-therapeutic male circumcision on 12 February 2023 and developed symptoms of illness three to four days later. He suffered a cardiorespiratory arrest while being taken to hospital and was declared dead on 19 February 2023; the inquest recorded invasive Streptococcus pyogenes infection following male circumcision as the medical cause of death. The report raised concerns about the lack of training, accreditation, record keeping, consent, infection-control requirements and aftercare requirements for individuals conducting such procedures.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain consent before NTMC
Wider context from the report “4. There is no system for consent to be taken prior to a Non-Therapeutic Male Circumcisions (NTMC) .
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of infection control requirements for NTMC
Wider context from the report “5. There is no requirement for any infection control measures for a Non-Therapeutic Male Circumcisions (NTMC).
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of external accreditation and registration for NTMC practitioners
Wider context from the report “2. There is no system of external accreditation and/or registration for individuals who conduct a Non-Therapeutic Male Circumcisions (NTMC).
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of record-keeping requirements for NTMC
Wider context from the report “3. There is no requirement for any record keeping for individuals who undergo a Non-Therapeutic Male Circumcisions (NTMC).
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of training and continuing professional development requirements for NTMC practitioners
Wider context from the report “1. Any individual may conduct a Non-Therapeutic Male Circumcision (NTMC) without any prior training or any Continuing Professional Development (CDP) ,
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of aftercare requirements for NTMC
Wider context from the report “6. There are no requirements for any aftercare for a Non-Therapeutic Male Circumcisions (NTMC) , including but not limited to dressing the wound, analgesia and/or worsening care advice .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for the reported issues rests with DHSC, which has provided the comprehensive government response; MHCLG has nothing further to add.
Verbatim wording from the response “MHCLG is responsible for the overall stewardship of the local government sector, but we are not responsible for all the services that councils deliver. Councils deliver a very wide range of services to residents, within a national legislative framework. Decisions around management are often taken locally, but the lead Government department for any particular issue delivered by a local authority is responsible for working with councils to ensure effective delivery.” Source location Response from MHCLG
Open published response
Concerns raised 5 Failure to routinely monitor formalin in mortuaries View source Lack of appreciation across mortuaries of the dangers posed by formalin to mortuary users View source Lack of availability of appropriate equipment for handling bodies significantly contaminated with formalin View source Frequent receipt of bodies preserved in formalin by mortuaries View source Failure to use appropriate equipment when handling bodies significantly contaminated with formalin View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Unnamed deceased persons · 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
Following an aircraft crash on 12 June 2025, the remains of deceased persons were repatriated to Westminster Public Mortuary wrapped and saturated with high concentrations of formalin. Dangerously high levels of formalin, carbon monoxide and cyanide were detected when coffins were opened and bodies were unwrapped. The report raises concerns about under-appreciation of formalin’s risks in mortuaries, the lack of routine monitoring, and the possible unavailability or non-use of appropriate protective equipment.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely monitor formalin in mortuaries
Wider context from the report “3. That formalin is not routinely monitored in mortuaries .
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of appreciation across mortuaries of the dangers posed by formalin to mortuary users
Wider context from the report “1. There is an under appreciation across mortuaries of the dangers posed by formalin to the health of all mortuary 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of availability of appropriate equipment for handling bodies significantly contaminated with formalin
Wider context from the report “4. That as such appropriate equipment may not be available nor used when mortuaries handle bodies significantly contaminated with formalin, thus exposing users of mortuaries to health risks including risk of death as outlined above in box 4.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Frequent receipt of bodies preserved in formalin by mortuaries
Wider context from the report “2. That mortuaries frequently receive bodies preserved in formalin .
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure to use appropriate equipment when handling bodies significantly contaminated with formalin
Wider context from the report “4. That as such appropriate equipment may not be available nor used when mortuaries handle bodies significantly contaminated with formalin , thus exposing users of mortuaries to health risks including risk of death as outlined above in box 4.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The matters raised fall outside the ministry’s policy responsibilities, so it will not provide a response to the reports.
Verbatim wording from the response “I can confirm that the matters raised do not fall within the policy responsibilities of the Ministry of Housing, Communities and Local Government. As such, we will not be providing a response to these reports. I have spoken to other Government Departments to ensure you will receive a Government response from the relevant Departments.” Source location Response from Ministry of Housing, Communities & Local Government
Open published response
8 Jul 2025 Peter Ramsden · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 1 Lack of emergency powers of entry for ambulance and fire services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter Ramsden · 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
Peter Ramsden, who had not been seen for approximately two months, was found deceased in an advanced state of decomposition at his premises on 2 January 2025. The inquest concluded that his death was from natural causes, although no specific disease process was identified. The principal concern was a perceived gap in the law concerning powers of entry for ambulance and fire services when an incapacitated person may require urgent treatment.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of emergency powers of entry for ambulance and fire services
Wider context from the report “Evidence was heard that there is a lacuna in the law, specifically relating to section 17 of the Police & Criminal Evidence Act 1984 (PACE) which grants police officers the power to enter and search premises without a warrant in specific situations. These include, inter alia, entry for arrest and emergency situations which allows entry to save life or limb or prevent serious damage to a property. In this particular case, evidence was heard that this man had not been seen for two months and there were concerns about his welfare and paramedics attended on one occasion but have no powers of entry . Due to the Right Care, Right Person model, which has been developed over the last few years, the police did not get involved, as it was thought by the concerned individual that this man not being seen was due to a medical problem. Evidence was heard which suggested that on occasions, the ambulance service and the fire service should have powers of entry in the event that a person who is ill, unconscious or otherwise incapacitated, with a remediable disorder, can receive prompt and potentially life-saving treatment. In this case, causation would not have been established as the man has been dead for several weeks, but situations could and will arise where time-sensitive pathological processes require emergency treatment to save life .
” Open source report
×
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 Engage Department of Health and Social Care counterparts about ambulance personnel access rights.
Verbatim wording from the response “CONCLUSION
We appreciate the very sad circumstances of the passing of Mr. Ramsden. Whilst in the opinion of the NFCC and FRAs, a statutory framework exists for FRAs to support the public in tragic situations like Mr. Ramsden’s, the NFCC suggests there is an argument for an extension of powers to ambulance services as it would improve speed of response and reduce the burden on FRAs. I am copying this letter to the Secretary of State at the Department of Health and Social Care (DHSC) to be aware of the comments concerning rights of access for ambulance personnel; I have also asked my officials to engage with their counterparts at DHSC on this topic.” Source location Response from Housing, communities and Local Government
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fire and rescue authorities cannot use PACE entry powers but possess independent statutory emergency entry powers under the Fire and Rescue Services Act 2004.
Verbatim wording from the response “Concerning the legal position, Fire and Rescue Authorities (FRAs), the legal body overseeing fire and rescue services, cannot lawfully operate under section 17 of the Police and Criminal Evidence Act. However, they do possess independent statutory powers of entry under section 44 of the Fire and Rescue Services Act 2004. In the event of an emergency, section 44(1)(c) and 44(2)(a) of the Act allows authorised FRA personnel to enter premises (by force if necessary) without the consent of the owner or occupier of the premises or place, if they reasonably believe entry is needed to protect life or property. Section 58(a) of the Act defines an ‘emergency’ as an event or situation likely to cause death, serious injury, or serious illness.” Source location Response from Housing, communities and Local Government
Open published response
Concerns raised 1 Insufficient availability of accommodation for people who are homeless View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Callum James Hargreaves · 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
Callum James Hargreaves, who had experienced homelessness, substance misuse issues and mental health concerns, was found deceased in the sea on 20 January 2024 after suffering multiple injuries consistent with a fall from height. The principal concern was the difficulty in securing suitable accommodation, with evidence that long periods of homelessness and frustrations about his housing situation contributed to his mental state at the time of his death.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of accommodation for people who are homeless
Wider context from the report “1) The court heard that, as at January 2025, there were approximately 26,000 families registered on the Cornwall Homechoice Register which is the service for letting council and housing association homes to rent in Cornwall. The court also heard there may only be about 1,000 properties available to let annually . This has obvious implications for Cornwall Council’s ability to provide accommodation for those who are homeless whether or not they present with priority needs . As matters of fact, it was established in evidence that there were long periods when Callum was homeless and further, that frustrations in relation to his housing situation contributed to his mental state at the time of his death.
” Open source report
×
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 Provide a ten-year rent settlement to enable social housing providers to invest in existing and new homes.
Verbatim wording from the response “Alongside this, we are providing a ten-year rent settlement so that social housing providers have the certainty to invest in their current homes and build new ones.” Source location Response from MHCLG
Open published response
×
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 Provide the 2025/26 Rough Sleeping Prevention and Recovery Grant to fund accommodation, outreach and specialist support through local authorities.
Verbatim wording from the response “As part of our spending on homelessness and rough sleeping, the government is also providing funding so that local authorities can support people who are rough sleeping in their area. The 2025/26 Rough Sleeping Prevention and Recovery Grant provides £185.6 million funding, including over £3.5 million for Cornwall Council so that local authorities can support individuals sleeping rough,” Source location Response from MHCLG
Open published response
×
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 Protect social rented housing stock by reducing maximum Right to Buy cash discounts.
Verbatim wording from the response “The government also made a manifesto commitment to protect existing social rented stock, and we have already taken action to achieve this - in November 2024, maximum Right to Buy cash discounts were returned to pre-2012 levels which we estimate will reduce sales from around 7,000 to 1,600 a year. On 2 July, we announced further details about other aspects of our reform programme, including regulations on quality and safety and Right to Buy, so that there is clarity and certainty needed to quickly ramp up investment in existing and new social housing stock.” Source location Response from MHCLG
Open published response
×
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 Increase social and affordable housing supply through the decade-long Social and Affordable Homes Programme.
Verbatim wording from the response “The government has committed to addressing this problem by delivering the biggest increase in social and affordable housebuilding in a generation. We are working urgently to increase supply so that those in society who are most vulnerable, such as Mr Hargreaves, are provided with safe and secure social housing to help them build their lives.” Source location Response from MHCLG
Open published response
×
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 Provide £1 billion in 2025/26 funding for homelessness and rough sleeping services, including funding for Cornwall Council.
Verbatim wording from the response “The government recognises that homelessness levels are far too high. This can have a devastating impact on those affected, as tragically seen in Mr Hargreaves’ case. Your report specifically raises concerns about Cornwall Council’s ability to accommodate people who are homeless. The government has increased funding for homelessness and rough sleeping services by £233 million to a total of £1 billion in 2025/26, including over £10.7 million for Cornwall Council. At the recent Spending Review, we protected this record level of investment.” Source location Response from MHCLG
Open published response
×
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 Provide £950 million in capital funding through the Local Authority Housing Fund to increase better-quality temporary accommodation.
Verbatim wording from the response “We are also providing £950m capital for the fourth round of the Local Authority Housing Fund - the largest round of the fund to date - to support local authorities in England to increase the supply of better-quality temporary accommodation. This investment aims to drive down the use of Bed and Breakfasts for families with children, improve outcomes for families in temporary accommodation, and to provide more stable, secure housing options for the most vulnerable, including those experiencing homelessness, while they wait for a permanent home.” Source location Response from MHCLG
Open published response
8 Apr 2025 Ruth Ann PINGREE · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 10 Lack of clear standards for achieving required fire-safety standards View source Lack of clear standards for required fire-safety measures View source Ad hoc fire-safety assurance and enforcement View source Lack of defined guidance, format, scope and frequency for fire-safety risk assessments View source Lack of required written fire-safety records View source Reliance on individual research ability to interpret fire-safety requirements View source Lack of clear standards for assessing applicable fire-safety measures View source Lack of required caravan fire-safety signage and emergency notices View source Failure to establish relevant fire-safety guidance as minimum standards View source Lack of specified intervals for maintenance inspections View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ruth Ann PINGREE · 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
Ruth Ann Pingree died after an accidental fire engulfed the caravan in which she was holidaying with her family. The caravan door became jammed, the smoke detector did not activate, and she was unable to escape before being overcome by fire fumes. The report raised concerns about a lack of clear standards for fire safety measures, risk assessments, and assurance and enforcement for businesses providing paid accommodation.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of clear standards for achieving required fire-safety standards
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard , and the assurance and enforcement mechanisms beyond this.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of clear standards for required fire-safety measures
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required , how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Ad hoc fire-safety assurance and enforcement
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of defined guidance, format, scope and frequency for fire-safety risk assessments
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of required written fire-safety records
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Reliance on individual research ability to interpret fire-safety requirements
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of clear standards for assessing applicable fire-safety measures
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied , how to achieve that standard, and the assurance and enforcement mechanisms beyond this.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of required caravan fire-safety signage and emergency notices
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure to establish relevant fire-safety guidance as minimum standards
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of specified intervals for maintenance inspections
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this.
” Open source report
×
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 Enhance the legal status of fire safety guidance under Section 156 of the Building Safety Act.
Verbatim wording from the response “Since the tragic death of Mrs Pingree, the Government has enhanced the status of guidance issued under Article 50 through Section 156 of the Building Safety Act, which now means that in any proceedings on a breach of the FSO, the court can consider whether failure to comply with guidance tends to establish if there was a contravention (with the converse point that compliance with guidance may be relied upon to establish there was no contravention).” Source location Response from Ministry of Housing, Communities and Local Government
Open published response
×
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 Publish updated fire safety guidance for small paying guest accommodation, including caravans and recommended fire precautions.
Verbatim wording from the response “The Government published an update to this guide titled “Making your small paying guest accommodation safe from fire” which superseded the older paying guests guide in March 2023 and is available as a free download on GOV.UK. The new guide tends to be more stringent in relation to the fire precautions it recommends.” Source location Response from Ministry of Housing, Communities and Local Government
Open published response
×
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 Require fire risk assessments to be recorded with all findings, rather than only significant findings.
Verbatim wording from the response “Since the fire, the Government has also changed the requirements on fire risk assessments where they all now need to be recorded, and it is no longer limited to just ‘significant’ findings but all findings.” Source location Response from Ministry of Housing, Communities and Local Government
Open published response
4 Apr 2025 Mr Alexi Susiluoto · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to include homelessness-related care issues in the review of treatment for patients with dual diagnoses View source Fragmented provision of substance misuse and mental health treatment across different organisations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Alexi Susiluoto · 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 Alexi Susiluoto, who had a history of mental health disorders, substance misuse and epilepsy, was found deceased in a hotel room on 22 May 2024. His death was attributed to alcohol misuse disorder resulting in acute ethanol toxicity, with epilepsy and prescribed medication as contributing factors. The report raised concerns about fragmented care for people with dual diagnoses who are homeless, including confusion over which services and local authority were responsible for care and funding.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure to include homelessness-related care issues in the review of treatment for patients with dual diagnoses
Wider context from the report “1. I heard evidence that the Office for Health Improvement and Disparities is currently undertaking a review of how patients with dual diagnoses (substance misuse and mental health disorders) are treated. I was concerned by two related issues:
a. That substance misuse and mental health treatment is routinely provided by different organisations, despite close interplay between these conditions and that this can result in significant complexities for agencies caring for the same patient. I understand that this aspect is part of the current review;
b. However, I also heard that the review is not taking into consideration the additional issues that arise when a patient with dual diagnoses is also homeless . Evidence presented at the inquest set out that this already complex situation is often compounded by homelessness, since individuals are often moved between temporary accommodation and therefore between different mental health trust and substance misuse providers. In Mr Susiluoto’s case, this resulted in significant confusion as to who was providing his care and which local authority would fund potential substance misuse treatment.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Fragmented provision of substance misuse and mental health treatment across different organisations
Wider context from the report “1. I heard evidence that the Office for Health Improvement and Disparities is currently undertaking a review of how patients with dual diagnoses (substance misuse and mental health disorders) are treated. I was concerned by two related issues:
a. That substance misuse and mental health treatment is routinely provided by different organisations , despite close interplay between these conditions and that this can result in significant complexities for agencies caring for the same patient . I understand that this aspect is part of the current review;
b. However, I also heard that the review is not taking into consideration the additional issues that arise when a patient with dual diagnoses is also homeless. Evidence presented at the inquest set out that this already complex situation is often compounded by homelessness, since individuals are often moved between temporary accommodation and therefore between different mental health trust and substance misuse providers. In Mr Susiluoto’s case, this resulted in significant confusion as to who was providing his care and which local authority would fund potential substance misuse treatment.
” Open source report
×
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 Work with the Department of Health and Social Care to improve access to mental health services and coordination across health services for people experiencing homelessness.
Verbatim wording from the response “I am leading cross-government efforts to deliver the long-term solutions we need to get us back on track to ending all forms of homelessness. This includes chairing a dedicated Inter-Ministerial Group (IMG), bringing together Ministers from across Government to develop a long-term strategy. DHSC Ministers attend the IMG, and we are working closely with the DHSC to address the health needs of people experiencing homelessness and rough sleeping. This includes improving access to mental health services and improving join-up between all services across the health system to ensure people experiencing homelessness are supported with all their health needs. We expect to publish our Homelessness Strategy following the conclusion of Phase 2 of the Spending Review.” Source location Response from MHCLG
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department of Health and Social Care will respond separately on matters relevant to its department, including the needs review.
Verbatim wording from the response “I understand the Parliamentary Under-Secretary of State for Public Health and Prevention in the DHSC will be responding separately on matters relevant to their department that your report raises,” Source location Response from MHCLG
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing actions and the cross-government homelessness strategy are considered sufficient, so no further Ministry action is proposed.
Verbatim wording from the response “Given the actions and relevant cross-government strategy being already undertaken and led by my department, I am proposing that no further action is taken by the Ministry of Housing, Communities and Local Government in relation to this case.” Source location Response from MHCLG
Open published response
Concerns raised 1 Delays in providing suitable accommodation for priority homeless families View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Williams · 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
On 9 July 2024, Paul Williams was found suspended from a ligature outside Screwfix, with police finding no suspicious circumstances. The inquest concluded that his death was suicide, with hanging recorded as the medical cause of death. The report identified eviction, homelessness, separation from his family while awaiting accommodation, and the resulting impact on his mental health as substantive concerns.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Delays in providing suitable accommodation for priority homeless families
Wider context from the report “The inquest heard that Paul Williams was a hard working family man in employment. He and his family had been evicted from their privately rented accommodation and became homeless. They were given a period of 2 weeks to leave the property and find alternative accommodation. Whilst looking for accommodation the family was forced to live in separate locations . In his case that included living in a vehicle in the week . The inquest was told that the family was a priority case but a shortage of public housing meant that in total they had to wait almost 3 months before suitable accommodation became available .
The evidence before the inquest was that the housing situation including the eviction, the homelessness and need to live separately whilst waiting for suitable accommodation to become available had a significant impact on his mental health and contributed to his deteriorating condition.
” Open source report
×
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 Provide £1.2 billion through the Local Authority Housing Fund for local authorities to acquire and create homes for families at risk of homelessness.
Verbatim wording from the response “The supply of temporary accommodation is extremely challenging nationwide. MHCLG administers the Local Authority Housing Fund, which is providing £1.2bn to local authorities to acquire and create homes for families at risk of homelessness and will create over 7,000 affordable homes for vulnerable families.” Source location Response from Ministry of Housing, Communities & Local Government
Open published response
×
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 Work with 20 local authorities through Emergency Accommodation Reduction Pilots to test approaches and initiate more suitable accommodation for homeless families.
Verbatim wording from the response “Additionally, MHCLG is also working with 20 local authorities through the new programme of Emergency Accommodation Reduction Pilots to test innovative approaches and kickstart new initiatives to provide more suitable accommodation for homeless families.” Source location Response from Ministry of Housing, Communities & Local Government
Open published response
×
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 Remind Stockport Metropolitan Borough Council to act early under the Homelessness Code of Guidance to prevent households reaching crisis situations.
Verbatim wording from the response “I am sorry that steps were not taken to offer and provide more suitable accommodation before the family faced this stage. I am writing to SMBC to remind them of this part of the code and the need to take sufficient action early enough to prevent households from being placed in a crisis situation by remaining until a possession order or bailiff warrant is issued.” Source location Response from Ministry of Housing, Communities & Local Government
Open published response
×
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 Deliver 1.5 million new homes by the end of the Parliament, including increased social and affordable housing.
Verbatim wording from the response “This government is committed to delivering 1.5 million new homes by the end of this Parliament, including the biggest increase in social housing and affordable housebuilding in a generation. In October 2024 and again in February 2025, we announced additional funding for the Affordable Homes Programme, which will build more social and affordable new homes, including Social Rent homes.” Source location Response from Ministry of Housing, Communities & Local Government
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local authorities, rather than the department, are responsible for assessing homelessness applications and providing suitable accommodation and support.
Verbatim wording from the response “My department is clear that local authorities must step in and assist households when they have received a section 21 notice and do so in a timely way. My department is responsible for the statutory framework that governs homelessness. The Housing Act 1996 Part 7 sets out the duties local housing authorities have towards homeless households, including the responsibilities for assessment, accommodation, and support. The Housing Act makes clear that a household is considered threatened with homelessness if they receive a section 21 notice which expires within 56 days and as a consequence is owed various duties under that Act.” Source location Response from Ministry of Housing, Communities & Local Government
Open published response
Concerns raised 2 Lack of available suitable Approved Premises accommodation for prisoners released from custody View source Lack of local-authority accommodation to prevent homelessness among prisoners released from custody View source
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
Barrie Forster · 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
Barrie Forster was assaulted on 20 November 2020 by a person who had been released from custody two days earlier, and the inquest recorded multi-organ failure following acute upper gastrointestinal haemorrhage and craniofacial trauma. The report identified failures to assess the risk posed to Barrie and the suitability of the address where the perpetrator intended to live. It also raised a broader concern about inadequate accommodation for people released from custody, resulting in homelessness or placement in unsuitable premises.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of available suitable Approved Premises accommodation for prisoners released from custody
Wider context from the report “There is a lack of accommodation available to the Probation Service in which prisoners released from custody may properly be placed. This includes both Approved Premises (which I understand to be the responsibility of the MoJ) and more generally through the local authority to avoid homelessness. As a consequence, some prisoners are released and become effectively homeless (with increased difficulties in supervision) while others are accommodated at unsuitable premises, as happened in this instance.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of local-authority accommodation to prevent homelessness among prisoners released from custody
Wider context from the report “There is a lack of accommodation available to the Probation Service in which prisoners released from custody may properly be placed. This includes both Approved Premises (which I understand to be the responsibility of the MoJ) and more generally through the local authority to avoid homelessness . As a consequence, some prisoners are released and become effectively homeless (with increased difficulties in supervision) while others are accommodated at unsuitable premises, as happened in this instance.
” Open source report
25 Oct 2024 Wessam al Jundi · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Lack of adequate water suppression systems for dust created during artificial stone finishing View source Inadequate respiratory personal protective equipment for artificial stone finishing View source Absent or inadequate ventilation systems for artificial stone finishing View source Health surveillance failing to detect disease before it becomes untreatable View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Wessam al Jundi · 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
Wessam al Jundi had severe silicosis and was admitted to Harefield Hospital on 17 May 2024 for a potential lung transplant, but was too unwell and died in hospital on 22 May 2024. The principal concern was that his untreatable lung disease was probably caused by workplace exposure to respirable crystalline silica from artificial stone products, in conditions described as unsafe and lacking adequate dust controls and respiratory protection.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate water suppression systems for dust created during artificial stone finishing
Wider context from the report “The last 2 decades have seen rapid growth in the use of artificial stone and this death demonstrates the emergence of a severe progressive accelerated form of silicosis. Many of the companies specialising in the finishing process of working with this product have a small number of employees and their appears to be an absence of safe working conditions, with no adequate water suppression systems for the dust created , in adequate respiratory personal protection equipment and absent or inadequate ventilatory systems. This is therefore continuing to put the workforce at risk of death due to untreatable lung compromise.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Inadequate respiratory personal protective equipment for artificial stone finishing
Wider context from the report “The last 2 decades have seen rapid growth in the use of artificial stone and this death demonstrates the emergence of a severe progressive accelerated form of silicosis. Many of the companies specialising in the finishing process of working with this product have a small number of employees and their appears to be an absence of safe working conditions, with no adequate water suppression systems for the dust created, in adequate respiratory personal protection equipment and absent or inadequate ventilatory systems. This is therefore continuing to put the workforce at risk of death due to untreatable lung compromise.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Absent or inadequate ventilation systems for artificial stone finishing
Wider context from the report “The last 2 decades have seen rapid growth in the use of artificial stone and this death demonstrates the emergence of a severe progressive accelerated form of silicosis. Many of the companies specialising in the finishing process of working with this product have a small number of employees and their appears to be an absence of safe working conditions, with no adequate water suppression systems for the dust created, in adequate respiratory personal protection equipment and absent or inadequate ventilatory systems . This is therefore continuing to put the workforce at risk of death due to untreatable lung compromise.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Health surveillance failing to detect disease before it becomes untreatable
Wider context from the report “Any current surveillance health and safety monitoring is unlikely to achieve a satisfactory outcome as the onset of untreatable disease predates the 15 year surveillance programmes. In this case exposure appears to have commenced in May 2016 and he was diagnosed with silicosis in 2021, a mere 5 years after initial exposure. Evidence from photographs and an in-life statement suggest Wessam was working in completely unsafe conditions to avoid dust exposure.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Working practices and protections fall outside MHCLG’s policy remit, so MHCLG policy would not address the concerns.
Verbatim wording from the response “Also attached is the Health and Safety Executive’s (HSE) response to the report. The concerns raised within the report relate to working practices and protections which would fall within the remit of HSE and the regulations its response set out. Policy owned by MHCLG would not be applicable in addressing these issues and there is consequently little substantive addition MHCLG could provide to HSE’s response.” Source location Response from MHCLG
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The concerns are matters for HSE under its remit and regulations, leaving little substantive addition to HSE’s response.
Verbatim wording from the response “Also attached is the Health and Safety Executive’s (HSE) response to the report. The concerns raised within the report relate to working practices and protections which would fall within the remit of HSE and the regulations its response set out. Policy owned by MHCLG would not be applicable in addressing these issues and there is consequently little substantive addition MHCLG could provide to HSE’s response.” Source location Response from MHCLG
Open published response
13 Aug 2024 Joanita Nalubowa · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Rigidity and lack of flexibility in criteria for aftercare outside section 117 View source
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
Joanita Nalubowa · 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
Joanita Nalubowa died after suspending herself with a ligature shortly after being told she would be discharged to Stockton, away from her family support network and against her wishes. The report raises concern that rigid accommodation criteria and the lack of discretion may create a risk of future deaths where a person's historical area of residence is inappropriate or dangerous and section 117 aftercare does not apply.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Rigidity and lack of flexibility in criteria for aftercare outside section 117
Wider context from the report “Please see Box 4, above.
The evidence at the Inquest was that this situation is not uncommon, with those detained under the MHA not infrequently having social circumstances such that their historical place of residency is, for whatever reason, deeply inappropriate (or even dangerous).
It should be noted that section 117 Mental Health Act 1983 did not apply.
I am concerned that the rigidity and lack of flexibility in the criteria , coupled with the evidence this is a not uncommon phenomenon, gives rise to a risk of future deaths in cases which do not meet the threshold for aftercare under s.117 .
” Open source report
7 Aug 2024 Malika HIBU · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Failure to make an identified unsafe barrier safer or secure its remediation View source Failure to risk assess the canal barrier View source Failure to consider barrier safety during housing development planning View source Failure to act on resident complaints about the barrier View source Lack of knowledge of the ownership boundary View source Inadequate canal-side railing protection for children and adults View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Malika HIBU · 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
Malika Hibu, a five-year-old girl with autism spectrum disorder, left her home, fell into Regent’s Canal on 17 February 2024, and died after efforts to resuscitate her. The report raised concerns that the canal-side railing did not protect small children, that the housing association had not adequately assessed or acted on safety concerns, and that the development’s planning process had not considered the barrier’s safety.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure to make an identified unsafe barrier safer or secure its remediation
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer .
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure to risk assess the canal barrier
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal ;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure to consider barrier safety during housing development planning
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development .
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure to act on resident complaints about the barrier
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier ;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of the ownership boundary
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished ;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Inadequate canal-side railing protection for children and adults
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it .
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” Open source report
×
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 Update the National Planning Policy Framework to require consideration of vulnerable users’ safety near open water, railways and other hazards.
Verbatim wording from the response “On 12 December 2024, the Government published an updated NPPF in response to the ‘Proposed reforms to the National Planning Policy Framework and other changes to the planning system’ consultation. As part of this update, and in direct response to findings set out in the Coroner’s report, additional policy has been added to paragraph 102 a) setting out that the safety of children and other vulnerable users in proximity to open water, railways and other potential hazards should be considered in planning and assessing proposals for development.” Source location Response from MHCLG
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Regulator of Social Housing assessed Peabody against regulatory standards and concluded that no further regulatory action was required.
Verbatim wording from the response “The Regulator of Social Housing has engaged directly with Peabody in relation to this tragic case and having assessed all relevant information against regulatory standards, has now concluded no further regulatory action will be taken. However, the Regulator will continue its regular engagement with Peabody and note the steps that Peabody is taking in response including working with other parties to address issues raised in the Prevention of Future Deaths notice.” Source location Response from MHCLG
Open published response
Concerns raised 1 Gaps between housing benefit and actual rent for larger properties View source
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
Lee Francis MCHALE · 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
Lee Francis McHale was admitted to hospital on 23 November 2023 after taking paracetamol tablets the previous day and died at Tameside General Hospital on 25 November 2023. The inquest heard that a gap between his housing benefit and rent, arising from the so-called “bedroom tax”, led to rent arrears and a risk of eviction; he was also worried about moving because an adult former foster child lived with him. The principal concern was the impact of housing benefit rules, rent arrears and threatened eviction on his circumstances before his death.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Gaps between housing benefit and actual rent for larger properties
Wider context from the report “The inquest was told that once Mr McHale was no longer able to foster he began to claim benefits including housing benefit. However the property he resided in was larger than a single occupancy property because he had previously fostered children. As a consequence he was subject to the so called “bedroom tax”. This meant that there was a gap between housing benefit and his actual rent. Therefore he rapidly went into arrears with his rent and liable to be evicted. He did not feel able to deal with the situation. He was worried about moving from his home in part because he had allowed one of his now adult foster children to continue living with him. He had allowed that because he was concerned that person would otherwise become homeless. Ultimately he took a catastrophic paracetamol overdose.
” Open source report
Concerns raised 3 Delays in organizations agreeing their roles View source Insufficient support to maintain physical health and promote abstinence View source Delays in accessing residential rehabilitation care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emily Rose Collishaw · 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
Emily Rose Collishaw, who was aged 35, was found dead in her flat on 6 September 2023 in non-suspicious circumstances. She had alcohol dependency and had been receiving mental health and substance misuse support, but was awaiting an inpatient rehabilitation placement. Concerns included delays and insufficient coordination and support, particularly the prolonged wait for residential rehabilitation and the associated risks to patients.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Delays in organizations agreeing their roles
Wider context from the report “1. Emily’s mother reported that it took some time for the organizations working with her daughter to agree their roles and that the degree of support was insufficient to maintain her physical health or promote abstinence over such a long period of six months before she died. The family felt that the referral for residential care should have been made earlier, especially as her housing situation was a risk to her health. It was accepted that Emily did not engage consistently but did reduce intake on a number of occasions, only to relapse.
2. The inquest heard from professionals that the period of waiting for a residential rehabilitation placement was about three months, but could be as long as seven months. Evidence was heard from the manager of the Pier Project that the delay in accessing residential care had been progressively getting longer over the last 10 years, which posed risks such as sudden death to patients.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Insufficient support to maintain physical health and promote abstinence
Wider context from the report “1. Emily’s mother reported that it took some time for the organizations working with her daughter to agree their roles and that the degree of support was insufficient to maintain her physical health or promote abstinence over such a long period of six months before she died. The family felt that the referral for residential care should have been made earlier, especially as her housing situation was a risk to her health. It was accepted that Emily did not engage consistently but did reduce intake on a number of occasions, only to relapse.
2. The inquest heard from professionals that the period of waiting for a residential rehabilitation placement was about three months, but could be as long as seven months. Evidence was heard from the manager of the Pier Project that the delay in accessing residential care had been progressively getting longer over the last 10 years, which posed risks such as sudden death to patients.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Delays in accessing residential rehabilitation care
Wider context from the report “1. Emily’s mother reported that it took some time for the organizations working with her daughter to agree their roles and that the degree of support was insufficient to maintain her physical health or promote abstinence over such a long period of six months before she died. The family felt that the referral for residential care should have been made earlier, especially as her housing situation was a risk to her health. It was accepted that Emily did not engage consistently but did reduce intake on a number of occasions, only to relapse.
2. The inquest heard from professionals that the period of waiting for a residential rehabilitation placement was about three months, but could be as long as seven months . Evidence was heard from the manager of the Pier Project that the delay in accessing residential care had been progressively getting longer over the last 10 years , which posed risks such as sudden death to patients.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department for Health and Social Care is the lead department responsible for responding to the report.
Verbatim wording from the response “Many thanks for sharing a copy of this coroner’s report into the death of Ms Emily Rose Collishaw. After reviewing the report, MHCLG officials do not consider that there is a specific policy angle here for us to respond to, so I am writing to confirm that there will not be a response from this Department. I have informed the Department for Health and Social Care who will be the lead Department responding to this report.” Source location Response from Ministry of Housing, Communities & Local Governments
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The report has no specific policy implications for this department, so it will not provide a response.
Verbatim wording from the response “Many thanks for sharing a copy of this coroner’s report into the death of Ms Emily Rose Collishaw. After reviewing the report, MHCLG officials do not consider that there is a specific policy angle here for us to respond to, so I am writing to confirm that there will not be a response from this Department. I have informed the Department for Health and Social Care who will be the lead Department responding to this report.” Source location Response from Ministry of Housing, Communities & Local Governments
Open published response
Concerns raised 4 Insufficient support-service capacity to assist palliative care patients to move to alternative accommodation View source Digital alternative-accommodation bidding process failing to provide accessible access View source Severe shortage of available alternative social housing View source Social housing adversely affecting residents’ health and wellbeing View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Colin Waterhouse · 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
Colin Waterhouse, who had pancreatic cancer and was receiving palliative treatment, was found suspended by a ligature on 11 September 2023; the inquest conclusion was suicide and the medical cause of death was hanging. The report raised concerns that unsuitable social housing and a difficult digital bidding system affected his health and mental wellbeing, while available support lacked the capacity to help him move and the shortage of housing made alternative accommodation unlikely.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Insufficient support-service capacity to assist palliative care patients to move to alternative accommodation
Wider context from the report “The inquest heard evidence that the social housing where Mr Waterhouse lived was such that it was impacted his overall health and wellbeing after his terminal cancer diagnosis. It was recognised that his housing was impacting his mental wellbeing but the support services available to him (as a palliative care patient) did not have the resources/capacity to assist him in moving to alternative accommodation for the last few months of his life.
The evidence was that because he lived in social housing he had to bid for alternative accommodation. The bidding process was digital and he struggled to manage that.
In addition even if he made a bid the chances of success was extremely slim given the huge demand for property. The inquest was told as an illustration that the Housing Association that he was a tenant of had 35,000 properties but a waiting list of 17,000.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Digital alternative-accommodation bidding process failing to provide accessible access
Wider context from the report “The inquest heard evidence that the social housing where Mr Waterhouse lived was such that it was impacted his overall health and wellbeing after his terminal cancer diagnosis. It was recognised that his housing was impacting his mental wellbeing but the support services available to him (as a palliative care patient) did not have the resources/capacity to assist him in moving to alternative accommodation for the last few months of his life.
The evidence was that because he lived in social housing he had to bid for alternative accommodation. The bidding process was digital and he struggled to manage that .
In addition even if he made a bid the chances of success was extremely slim given the huge demand for property. The inquest was told as an illustration that the Housing Association that he was a tenant of had 35,000 properties but a waiting list of 17,000.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Severe shortage of available alternative social housing
Wider context from the report “The inquest heard evidence that the social housing where Mr Waterhouse lived was such that it was impacted his overall health and wellbeing after his terminal cancer diagnosis. It was recognised that his housing was impacting his mental wellbeing but the support services available to him (as a palliative care patient) did not have the resources/capacity to assist him in moving to alternative accommodation for the last few months of his life.
The evidence was that because he lived in social housing he had to bid for alternative accommodation. The bidding process was digital and he struggled to manage that.
In addition even if he made a bid the chances of success was extremely slim given the huge demand for property . The inquest was told as an illustration that the Housing Association that he was a tenant of had 35,000 properties but a waiting list of 17,000 .
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Social housing adversely affecting residents’ health and wellbeing
Wider context from the report “The inquest heard evidence that the social housing where Mr Waterhouse lived was such that it was impacted his overall health and wellbeing after his terminal cancer diagnosis . It was recognised that his housing was impacting his mental wellbeing but the support services available to him (as a palliative care patient) did not have the resources/capacity to assist him in moving to alternative accommodation for the last few months of his life.
The evidence was that because he lived in social housing he had to bid for alternative accommodation. The bidding process was digital and he struggled to manage that.
In addition even if he made a bid the chances of success was extremely slim given the huge demand for property. The inquest was told as an illustration that the Housing Association that he was a tenant of had 35,000 properties but a waiting list of 17,000.
” Open source report
×
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 Introduce Awaab’s Law in the social rented sector by bringing forward secondary legislation.
Verbatim wording from the response “We will also engage with the sector and set out more detail in the autumn on our plans to raise standards on quality, and strengthen residents’ voices. We are committed to introducing Awaab’s Law to the social rented sector, and will set out more detail and bring forward the secondary legislation to implement this in due course. Further details on my announcement can be found at https://www.gov.uk/government/news/housing-targets-increased-to-get-britain-building-again.” Source location Response from DLUHC
Open published response
×
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 Set out future Government investment in social and affordable housing at the Spending Review.
Verbatim wording from the response “On 30 July, I set out our first steps in this Government’s plan to build the homes this country needs and to deliver on our commitment to the biggest growth in social and affordable housebuilding in a generation. We will set out details of future Government investment in social and affordable housing at the Spending Review, so that social housing providers can plan for the future and help deliver the biggest increase in affordable housebuilding in a generation.” Source location Response from DLUHC
Open published response
×
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 Create over 2,000 affordable homes through the third round of the Local Authority Housing Fund.
Verbatim wording from the response “To further empower and enable councils to build their own stock of affordable homes, I also confirmed £450 million investment in councils across England under the third round of the Local Authority Housing Fund. This will create over 2,000 affordable homes for some of the most vulnerable families in society, including families currently living in cramped and unsuitable bed and breakfasts.” Source location Response from DLUHC
Open published response
×
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 Test whether more can be done to support developments focused predominantly or exclusively on affordable tenures, particularly Social Rent.
Verbatim wording from the response “In the first instance, this Government’s aspiration is to ensure that, in the first full financial year of this Parliament (2025-26), the number of Social Rent homes is rising rather than falling. I have also set out a clear expectation that housing needs assessments must consider those requiring Social Rent homes, and that local authorities should specify their expectations on Social Rent delivery as part of broader affordable housing policies. This includes testing whether there is more that could be done to support developments that are predominately or exclusively affordable tenures, in particular Social Rent.” Source location Response from DLUHC
Open published response
×
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 Set expectations that housing needs assessments consider households requiring Social Rent homes and that councils specify Social Rent delivery expectations.
Verbatim wording from the response “In the first instance, this Government’s aspiration is to ensure that, in the first full financial year of this Parliament (2025-26), the number of Social Rent homes is rising rather than falling. I have also set out a clear expectation that housing needs assessments must consider those requiring Social Rent homes, and that local authorities should specify their expectations on Social Rent delivery as part of broader affordable housing policies. This includes testing whether there is more that could be done to support developments that are predominately or exclusively affordable tenures, in particular Social Rent.” Source location Response from DLUHC
Open published response
×
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 Engage with the housing sector and set out plans to raise housing quality standards and strengthen residents’ voices.
Verbatim wording from the response “We will also engage with the sector and set out more detail in the autumn on our plans to raise standards on quality, and strengthen residents’ voices. We are committed to introducing Awaab’s Law to the social rented sector, and will set out more detail and bring forward the secondary legislation to implement this in due course. Further details on my announcement can be found at https://www.gov.uk/government/news/housing-targets-increased-to-get-britain-building-again.” Source location Response from DLUHC
Open published response
×
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 Increase councils’ flexibility to use Right to Buy receipts for replacement affordable homes, including combining receipts with section 106 contributions.
Verbatim wording from the response “More immediately, we have increased the flexibilities on how councils can use their Right to Buy receipts. The Government has removed the caps on the percentage of replacements delivered as acquisitions and the percentage cost of a replacement home that can be funded using Right to Buy receipts, and councils have been given the ability to combine Right to Buy receipts with section 106 contributions. These flexibilities will be in place for an initial 24 months, subject to review.” Source location Response from DLUHC
Open published response
×
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 Provide £450 million through the Local Authority Housing Fund to support councils in delivering affordable homes.
Verbatim wording from the response “To further empower and enable councils to build their own stock of affordable homes, I also confirmed £450 million investment in councils across England under the third round of the Local Authority Housing Fund. This will create over 2,000 affordable homes for some of the most vulnerable families in society, including families currently living in cramped and unsuitable bed and breakfasts.” Source location Response from DLUHC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local authorities and housing associations are responsible for assisting applicants who struggle with bidding and preventing unlawful discrimination.
Verbatim wording from the response “Accessibility of Social Housing bidding process
Under the statutory framework, local authorities must provide any assistance necessary, free of charge, to enable people who would have difficulty to make an application. This is also reflected in social housing allocations statutory guidance which is issued to local housing authorities.” Source location Response from DLUHC
Open published response
Concerns raised 2 Lack of a requirement to retrofit fixed window restrictors to existing windows View source Lack of Building Regulations requiring fixed window restrictors on opening windows in high-rise residential buildings View source
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
William Erskine · 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
William Erskine died on 26 August 2023 after falling or jumping from the open window of his 16th-floor flat, sustaining multiple injuries. Concerns were raised that the windows could be fully opened because their restrictors could be released, and that current requirements do not require fixed window restrictors in high-rise residential buildings or their retrofitting to windows of this type.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of a requirement to retrofit fixed window restrictors to existing windows
Wider context from the report “In the course of the evidence before the court, it was established that, whilst the windows in Mr Erskine’s flat were fitted with locks and dual-position window restrictors, the relevant restrictors can be released enabling the window to fully rotate within the frame (nominally to enable the resident to clean the glass). The degree to which the windows can be opened is therefore not restricted in the same way as if fixed window restrictors were fitted.
1. It is a matter of concern that, aside from certain buildings designed for educational or healthcare use, or provided for vulnerable adults, current Building Regulations do not require fixed window restrictors to be fitted to opening windows in high-rise residential buildings; and
2. In relation to windows of the type and design in use in Stretford House, there is no current requirement to retro-fit fixed window restrictors .
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of Building Regulations requiring fixed window restrictors on opening windows in high-rise residential buildings
Wider context from the report “In the course of the evidence before the court, it was established that, whilst the windows in Mr Erskine’s flat were fitted with locks and dual-position window restrictors, the relevant restrictors can be released enabling the window to fully rotate within the frame (nominally to enable the resident to clean the glass). The degree to which the windows can be opened is therefore not restricted in the same way as if fixed window restrictors were fitted.
1. It is a matter of concern that, aside from certain buildings designed for educational or healthcare use, or provided for vulnerable adults, current Building Regulations do not require fixed window restrictors to be fitted to opening windows in high-rise residential buildings ; and
2. In relation to windows of the type and design in use in Stretford House, there is no current requirement to retro-fit fixed window restrictors.
” Open source report
Concerns raised 7 Lack of resources for stable housing solutions for vulnerable young people View source Lack of overall ownership for coordinated multi-agency support View source Lack of resources for sustained support of vulnerable young people experiencing homelessness View source Delays in access to mental health support View source Failure of public service contact arrangements for people without a stable address View source Failure to recognise sexual exploitation and vulnerability among homeless LGBTQIA young people View source Failure to use regular MDTs to share and understand multi-agency information View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tobias Ryse Mannering-Jones · 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
Tobias Mannering-Jones became homeless, isolated and vulnerable, experienced mental health difficulties, drug use and sexual exploitation, and was found dead at Portland Basin Marina on 21 February 2023. The inquest identified concerns about delays in mental health support, inadequate housing and sustained support for vulnerable homeless young people, difficulties contacting people without telephones or addresses, failure to recognise exploitation, and the need for coordinated agency responsibility.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of resources for stable housing solutions for vulnerable young people
Wider context from the report “2. The inquest also heard evidence of the impact of homelessness and consequential vulnerability on a young person like Tobias and that the demands on Local Authorities meant that even where vulnerability was recognised there were not resources for either sustained support and stable housing solutions . The evidence was that as a consequence young vulnerable people had to rely on homeless shelters where they were exposed to additional negative influences and as in Tobias’s case abuse due to their sexuality.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of overall ownership for coordinated multi-agency support
Wider context from the report “5. The evidence before the inquest was that where multiple agencies were involved it was fundamental that one agency/person took overall ownership/responsibility to ensure a coordinated and effective approach using regular MDTs to understand the information that all agencies had in their possession and to offer effective support.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of resources for sustained support of vulnerable young people experiencing homelessness
Wider context from the report “2. The inquest also heard evidence of the impact of homelessness and consequential vulnerability on a young person like Tobias and that the demands on Local Authorities meant that even where vulnerability was recognised there were not resources for either sustained support and stable housing solutions. The evidence was that as a consequence young vulnerable people had to rely on homeless shelters where they were exposed to additional negative influences and as in Tobias’s case abuse due to their sexuality.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Delays in access to mental health support
Wider context from the report “1. The inquest was told that Tobias had sought and had been referred for mental health support however due to the high demand and long waiting lists he was still on a waiting list at the time of his death . The evidence before the inquest was that long delays were still an issue and were not restricted to Tameside but were part of a national picture of delays and long waiting lists for those seeking help with their mental health .
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure of public service contact arrangements for people without a stable address
Wider context from the report “3. Evidence was also heard that a person who has to rely on a homeless shelter can then become uncontactable to public service providers as they have no address for contact which means they then have even less chance of accessing support .
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise sexual exploitation and vulnerability among homeless LGBTQIA young people
Wider context from the report “4. The inquest was told that young adults who are homeless are often sexually exploited and that those who identify as LGBTQIA can be particularly vulnerable and that the underlying vulnerability and risk was not always appreciated by those dealing with young homeless people and that it could be mistaken by agencies as a lifestyle choice rather than what it actually was, i.e., exploitation by an older adult .
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure to use regular MDTs to share and understand multi-agency information
Wider context from the report “5. The evidence before the inquest was that where multiple agencies were involved it was fundamental that one agency/person took overall ownership/responsibility to ensure a coordinated and effective approach using regular MDTs to understand the information that all agencies had in their possession and to offer effective support.
” Open source report
×
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 Fund sector training and resources on safeguarding and safe service delivery for night shelters.
Verbatim wording from the response “DLUHC is also providing funding to Housing Justice (a national membership charity for homeless shelters) to deliver training to the night shelter sector, including online resources, webinars and briefings on safeguarding and how to deliver a safe service for all. Housing Justice operates a night shelter accreditation system, which is designed to help night shelters deliver the best possible service and provides independent external validation by issuing a Quality Mark. I will continue work with Housing Justice and other partner organisations to support high-quality night shelter provision, including through the current NSTF and wider homelessness and rough sleeping funding.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
×
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 Embed multi-agency review processes after the death of someone experiencing homelessness or rough sleeping.
Verbatim wording from the response “Alongside the work on SABs, DLUHC is working with sector organisations and LAs to embed multi-agency review processes following the death of someone who is homeless or rough sleeping, even where they do not meet the criteria for a formal Safeguarding Adult Review⁶.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
×
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 Operate the Night Shelter Transformation Fund to help providers improve services and transition toward self-contained accommodation.
Verbatim wording from the response “Secondly, addressing concerns with night shelter provision, my Department has action underway to support the sector to enhance services and improve outcomes for people experiencing homelessness and rough sleeping. In 2022, DLUHC established the Night Shelter Transformation Fund (NSTF), which is a £13 million programme over three years, making single and multi-year grant funding available to night shelter providers to transform their offer to provide sustainable routes off the streets through a range of high-quality provision. A key aspect of this is supporting organisations to transition from communal sleeping to a model of more self-contained accommodation, which, following the pandemic, is widely recognised as a more suitable type of accommodation providing people with increased safety, stability and dignity.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
×
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 Deliver Rough Sleeping Accommodation Programme move-on homes nationally.
Verbatim wording from the response “Alongside this, I am taking action to increase capacity and access to housing through our accommodation programmes. These include the £433 million Rough Sleeping Accommodation Programme (which has delivered over 5,500 move-on homes nationally as of March 2024); and the £200 million Single Homelessness Accommodation Programme (SHAP). SHAP was launched in 2022 and aims to provide both accommodation and wrap-around support specifically targeted at two groups: adults experiencing multiple disadvantages with a history of rough sleeping and who require high levels of support; and young people at risk of experiencing homelessness or rough sleeping. We expect around 650 units to be provided to support young people aged 18-25 across the country. I am pleased that Tameside is part of both of these programmes and has been allocated c.£3.1 million for RSAP and c.£1.5 million for SHAP.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
×
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 Coordinate Changing Futures pilots to improve joined-up local support for people experiencing multiple disadvantages.
Verbatim wording from the response “Secondly, my Department is co-ordinating a cross-government initiative to improve the way local public services engage and support people experiencing multiple disadvantages. ‘Changing Futures’ is a £77 million programme piloting innovative approaches across 15 local areas (covering 34 top-tier LAs in England), to join-up local systems and more effectively respond to the needs of people who are experiencing combinations of homelessness, substance misuse, mental health issues, domestic abuse and contact with the criminal justice system. The programme runs to March 2025 with an evaluation underway. I will publish the final learnings and outcomes from the pilots in 2025, and in the meantime interim evaluation reports and learning are published online to help disseminate learning⁷.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
×
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 Continue delivering Rough Sleeping Initiative funding to support specialist mental health services in local homelessness plans.
Verbatim wording from the response “DHSC will provide more information on this matter in their response, given their lead on health. I recognise the vital role mental health services play in supporting people experiencing homelessness and rough sleeping, and my Department is supporting provision where it is needed through the Rough Sleeping Initiative (RSI). This is providing over £547 million, between April 2022 to March 2025, to LAs across England to deliver local homelessness and rough sleeping services. Of that, £30 million is funding health interventions, with a significant focus on mental health. Through our expert homelessness and rough sleeping advisers in DLUHC, I will continue to deliver RSI funding this financial year, supporting LAs to deliver specialist mental health support where it is part of their local plans.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
×
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 Share NICE homelessness guidance across housing, homelessness and health sectors to promote person-centred, trauma-informed support.
Verbatim wording from the response “• Trauma-Informed Approach: In March 2022, the National Institute for Health and Care Excellence (NICE) published guidelines on ‘integrated health and social care for people experiencing homelessness’⁵. This guidance has been widely shared with LAs and across housing, homelessness and health sectors, to promote best practice guidance in supporting someone experiencing homelessness. The guidance sets out how services and staff should be person-centred, empathic, non-judgemental and trauma-informed, with specific references to specialist support for a person who identifies as LGBT.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
×
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 Provide dedicated youth homelessness advisers to support local authorities with joint protocols between housing and children’s services.
Verbatim wording from the response “I am committed to embedding fully the Homelessness Reduction Act 2017 and as part of this, I have also put in place bespoke support through DLUHC’s Homelessness Advice and Support Team, which includes dedicated youth homelessness advisers that work with LAs to promote positive joint working across housing authorities and children’s services. In carrying out their statutory duties, LAs must have regard to statutory guidance, including ‘Prevention of Homelessness and Provision of accommodation for 16 and 17 year olds who may be homeless and/or require accommodation’²; which sets a clear expectation that LAs implement joint protocols between housing and children’s services.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
×
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 Deliver the Single Homelessness Accommodation Programme, including accommodation and wrap-around support for vulnerable adults and young people.
Verbatim wording from the response “Alongside this, I am taking action to increase capacity and access to housing through our accommodation programmes. These include the £433 million Rough Sleeping Accommodation Programme (which has delivered over 5,500 move-on homes nationally as of March 2024); and the £200 million Single Homelessness Accommodation Programme (SHAP). SHAP was launched in 2022 and aims to provide both accommodation and wrap-around support specifically targeted at two groups: adults experiencing multiple disadvantages with a history of rough sleeping and who require high levels of support; and young people at risk of experiencing homelessness or rough sleeping. We expect around 650 units to be provided to support young people aged 18-25 across the country. I am pleased that Tameside is part of both of these programmes and has been allocated c.£3.1 million for RSAP and c.£1.5 million for SHAP.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
×
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 Continue supporting night shelters through training resources, high-quality accommodation requirements and specialist outreach roles funded through the Rough Sleeping Initiative.
Verbatim wording from the response “In DLUHC, I will continue to support the night shelter sector in line with the actions in the second matter of concern, including training resources on best practice for engagement; and will continue to ensure that areas in receipt of RSI funding have in place ending rough sleeping plans that include high quality off the street accommodation and specialist outreach roles that are designed to directly engage and support people on the streets. Shelters play a valuable role providing accommodation to those experiencing homelessness and lessons from matter of concern five are particularly pertinent in considering how this provision fits in and engages with other services.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
×
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 Work with Homeless Link to develop training covering safeguarding support for people whose protected characteristics, particularly sexuality, increase vulnerability.
Verbatim wording from the response “• Training: DLUHC’s Voluntary and Community Frontline Sector Grant is a three-year £7.3 million investment which funds sector experts to provide co-ordination, training and capacity building within the homelessness workforce. As part of our plans for 2024/25, our partner Homeless Link are developing training and online content exploring the role of safeguarding adult boards and partnerships when supporting vulnerable people sleeping rough. In response to the Report, DLUHC will work closely with Homeless Link to ensure that training material for 2024/25 covers supporting people whose protected characteristics may make them vulnerable, particularly sexuality.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Manchester Integrated Care Board is expected to provide further information on integrating local services for coordinated support.
Verbatim wording from the response “I expect Manchester Integrated Care Board to provide more information on the integration of local services related to this matter of concern in their response.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Health-related concerns are led by DHSC, with DHSC and Manchester Integrated Care Board providing a separate, more detailed response.
Verbatim wording from the response “My responses to the matters of concern are set out in turn below. I have worked closely with the other public bodies that have received the Report, including the Department of Health and Social Care (DHSC) and NHS England, in collaboration with Manchester Integrated Care Board. A separate response will be provided by DHSC and Manchester Integrated Care Board, which will respond in greater detail to the first, third and fifth matter of concern.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
Concerns raised 3 Lack of an industry standard requiring electricity meters to be accessible by all potential customers View source Failure to site electricity meters where their access is visible and unobstructed by inward-opening doors View source Failure to site electricity meters at a height accessible without steps View source
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
Bernadette Grace FAULKNER · 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
Bernadette Grace Faulkner fell from a stepladder while accessing an electricity pre-payment meter located 7–8 feet above the ground. She was discovered several hours later and died in hospital on 8 December 2022 from injuries sustained in the fall. The principal concern was that the meter’s height and location required ladder access and created risks, including poor visibility to people entering through the communal door; there also appeared to be no industry standard requiring meters to be readily accessible by all customers.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of an industry standard requiring electricity meters to be accessible by all potential customers
Wider context from the report “(1) The electricity meter was installed at such a height that anyone wishing to access it would be unable to do so without the use of steps/a ladder. In addition, the placement of the meter (immediately behind an inwardly opening front door with no windows) added to the risk of using a stepladder because anyone coming through the door would be entirely unable to see anyone using a stepladder behind the door. Irrespective of the type of meter, it is reasonably foreseeable that electricity meters need to be accessed by people from time to time and not only those with the requisite training for working at height.
(2) Siting prepayment meters, in particular, at such a height and location adds to the risk, because those choosing to use a pre-payment meter are required to access it each and every time they top-up the meter.
(3) The electricity company which installed the meter in 2001 has “no records of what consideration they gave at the point of installation to the specific meter location.” Other meters in the property are at a similar height and it is not uncommon to find electricity meters at heights requiring steps to access them; there appears to be no industry standard requiring electricity meters to be easily accessible (albeit secure) by all potential customers , except perhaps in new build properties.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure to site electricity meters where their access is visible and unobstructed by inward-opening doors
Wider context from the report “(1) The electricity meter was installed at such a height that anyone wishing to access it would be unable to do so without the use of steps/a ladder. In addition, the placement of the meter (immediately behind an inwardly opening front door with no windows) added to the risk of using a stepladder because anyone coming through the door would be entirely unable to see anyone using a stepladder behind the door . Irrespective of the type of meter, it is reasonably foreseeable that electricity meters need to be accessed by people from time to time and not only those with the requisite training for working at height.
(2) Siting prepayment meters, in particular, at such a height and location adds to the risk, because those choosing to use a pre-payment meter are required to access it each and every time they top-up the meter.
(3) The electricity company which installed the meter in 2001 has “no records of what consideration they gave at the point of installation to the specific meter location.” Other meters in the property are at a similar height and it is not uncommon to find electricity meters at heights requiring steps to access them; there appears to be no industry standard requiring electricity meters to be easily accessible (albeit secure) by all potential customers, except perhaps in new build properties.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure to site electricity meters at a height accessible without steps
Wider context from the report “(1) The electricity meter was installed at such a height that anyone wishing to access it would be unable to do so without the use of steps/a ladder . In addition, the placement of the meter (immediately behind an inwardly opening front door with no windows) added to the risk of using a stepladder because anyone coming through the door would be entirely unable to see anyone using a stepladder behind the door. Irrespective of the type of meter, it is reasonably foreseeable that electricity meters need to be accessed by people from time to time and not only those with the requisite training for working at height.
(2) Siting prepayment meters, in particular, at such a height and location adds to the risk, because those choosing to use a pre-payment meter are required to access it each and every time they top-up the meter.
(3) The electricity company which installed the meter in 2001 has “no records of what consideration they gave at the point of installation to the specific meter location.” Other meters in the property are at a similar height and it is not uncommon to find electricity meters at heights requiring steps to access them ; there appears to be no industry standard requiring electricity meters to be easily accessible (albeit secure) by all potential customers, except perhaps in new build properties.
” Open source report
Concerns raised 1 Failure to ensure care residents keep their pendant close to them at all times View source
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
Jill BRICE · 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
Jill Brice died on 23 December 2022 at Royal Sussex County Hospital after suffering burn injuries and smoke inhalation when an extractor fan in her sheltered housing caught fire. The substantive concern was that care residents should be reminded to keep their emergency pendants close to them, as Jill Brice was not wearing hers when she died.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure care residents keep their pendant close to them at all times
Wider context from the report “The Fire Safety Report recommended that care residents be reminded to have their pendant close to them at all times . I would like reassurance that this be actioned.
” Open source report
Concerns raised 2 Lack of a register providing local authorities with current private landlord address and contact details View source Ambulance-service policies advising people with non-immediately-life-threatening chest pain to attend A&E alone View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Luke Matthew Brooks · 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
Luke Matthew Brooks died unexpectedly at home on 25 October 2022 after approximately one week of cold/flu-like symptoms. The inquest recorded acute respiratory distress syndrome due to Aspergillus pneumonia. Concerns included the absence of a register of private landlords and an ambulance-service policy advising people with non-immediately life-threatening chest pain to attend A&E on their own.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of a register providing local authorities with current private landlord address and contact details
Wider context from the report “1. There is no register of Private landlords available in England. The court heard this was without other countries within the UK who had a national register. The lack of this meant that Local authorities could be hampered in not knowing up to date address/contact details when they were made aware of concerns with a privately rented property. This is particularly important when the issue is one which is potentially life threatening ie asbestos in a property, dangerous items such as inappropriate cord blinds in a property with children or excessive damp.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Ambulance-service policies advising people with non-immediately-life-threatening chest pain to attend A&E alone
Wider context from the report “2. NWAS had a local policy of advising people who described symptoms of chest pain (not immediate life threatening) to attend A&E on their own. Whilst NWAS have now revised this policy to remove this, it is not known if this could be set out in the local policies of other ambulance services .
” Open source report
×
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 Establish a mandatory private rented sector database and digital property portal for landlord, property and compliance information, subject to parliamentary approval.
Verbatim wording from the response “We are taking action to address this. The Renters (Reform) Bill was introduced to parliament on 17 May 2023 and includes provision for a new private rented sector database that will support the new Privately Rented Property Portal digital service. Subject to parliamentary approval, all private residential landlords (letting property in England via an assured tenancy under the Housing Act 1988 or a regulated tenancy under the Rent Act 1977) will be legally required to register with the Property Portal, and to provide certain information relating to the properties they let.” Source location Response from Department for Levelling up, Housing and Communities
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department of Health and Social Care will respond separately to the concern about ambulance-service advice for chest-pain patients.
Verbatim wording from the response “2. North West Ambulance Service (“NWAS”) had a local policy of advising people who described symptoms of chest pain (not immediate life threatening) not to attend A&E on their own. Whilst NWAS have now revised this policy to remove this, it is not known if this could be set out in the local policies of other ambulance services.” Source location Response from Department for Levelling up, Housing and Communities
Open published response
Concerns raised 2 Lack of compulsory fire safety measures for extra care and retirement-type accommodation View source Failure of fire safety consultation scope to cover extra care facility risks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brian George Harfield · 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
On 3 May 2022, a fire started near Brian George Harfield’s recliner chair and he was overcome by smoke. He was found unconscious and, despite medical intervention, was pronounced deceased at the scene. The principal concern was the lack of compulsory sprinklers or other fire-safety measures in extra-care and retirement-type accommodation outside care homes, particularly for people with declining health or mobility.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of compulsory fire safety measures for extra care and retirement-type accommodation
Wider context from the report “The concerns relates to the fact that there is a lack of compulsory provision for sprinklers or other fire safety measures to protect those who live at home (outside of care homes) but are being provided with extra care facilities or those in retirement type provision .
Due to there being an ageing population and a lack of care home spaces there is a growing number of people (who would normally be residing in care homes) who are now having to buy care packages to be delivered either in their own homes or other residential type of facilities. The providers of such accomodation are not subject to any fire safety provisions . People who find themselves in this type of facility do suffer declining health and mobility as time goes on. They are at a particular risk should a fire occur. They are more at risk than those in care homes as there is 24/7 staffing and trained individuals who are well versed in premises.
In an extra care facility it is highly probable that should a fire start that the occupant would be unable to leave the room of fire origin/ flat of origin through ill health/ poor mobility, and who would be overcome by the toxic products of combustion prior to the Fire and Rescue service being alerted. This is exactly what happened in Mr Harfield’s case.
We heard at this Inquest that whilst a sprinkler controlled fire would still produce smoke it would be of a lower level, and there is evidence that on the majority of occasions it does not just restrict the fires growth, but actually extinguishes it.
It is understood that there is currently a Government consultation being undertaken on the subject of Sprinklers in Care homes but the scope of this consultation does not cover the specific risk to those in extra care facilities. This is a missed opportunity.
The consultation can be found here. Sprinklers in care homes, removal of national classes, and staircases in residential buildings - GOV.UK (www.gov.uk)
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure of fire safety consultation scope to cover extra care facility risks
Wider context from the report “The concerns relates to the fact that there is a lack of compulsory provision for sprinklers or other fire safety measures to protect those who live at home (outside of care homes) but are being provided with extra care facilities or those in retirement type provision.
Due to there being an ageing population and a lack of care home spaces there is a growing number of people (who would normally be residing in care homes) who are now having to buy care packages to be delivered either in their own homes or other residential type of facilities. The providers of such accomodation are not subject to any fire safety provisions. People who find themselves in this type of facility do suffer declining health and mobility as time goes on. They are at a particular risk should a fire occur. They are more at risk than those in care homes as there is 24/7 staffing and trained individuals who are well versed in premises.
In an extra care facility it is highly probable that should a fire start that the occupant would be unable to leave the room of fire origin/ flat of origin through ill health/ poor mobility, and who would be overcome by the toxic products of combustion prior to the Fire and Rescue service being alerted. This is exactly what happened in Mr Harfield’s case.
We heard at this Inquest that whilst a sprinkler controlled fire would still produce smoke it would be of a lower level, and there is evidence that on the majority of occasions it does not just restrict the fires growth, but actually extinguishes it.
It is understood that there is currently a Government consultation being undertaken on the subject of Sprinklers in Care homes but the scope of this consultation does not cover the specific risk to those in extra care facilities . This is a missed opportunity .
The consultation can be found here. Sprinklers in care homes, removal of national classes, and staircases in residential buildings - GOV.UK (www.gov.uk)
” Open source report
×
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 Amend Approved Document B to reduce the height threshold for sprinkler provisions in blocks of flats, including applicable extra-care buildings.
Verbatim wording from the response “My department and the new Building Safety Regulator keep guidance in Approved Document B including sprinkler provisions under close review. In 2020, the Government amended Approved Document B to reduce the height threshold (from 30 metres to 11 metres) for the inclusion of sprinklers in blocks of flats; this included extra care buildings designed as blocks of flats. The Building Safety Regulator now has a dedicated workstream to consider what additional fire safety measures may be necessary in specialised housing for vulnerable people, including in extra care facilities.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
×
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 Conduct and commission phased research on sprinklers and other fire-protection measures in specialised housing.
Verbatim wording from the response “The Government recognises that further evidence is required on the benefit of sprinklers and other additional fire protection measures in specialised housing and, to this end, we have a dedicated research workstream in place. I will consider future research findings in light of your concerns and the evidence heard at Mr Harfield’s inquest, so that we can consider what changes are necessary to reduce the risk of similar incidents in the future. We have commissioned future research that will inform us of the benefit of sprinklers over other policy options such as enhancing fire detection and alarms or additional fire compartmentation. This will generate up-to-date evidence to help us review current building regulation policy and inform future changes.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
×
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 Bring into force landlord requirements for smoke alarms on each storey and carbon monoxide alarms in rooms with fixed combustion appliances, including repair or replacement of faulty alarms.
Verbatim wording from the response “Residents in both new and existing extra care buildings have the right to expect safe, quality, healthy environments and there should be full consideration of the risks in a building to determine the right protection to keep residents safe. My department has taken steps to improve safety for people in privately and socially rented homes. The Smoke and Carbon Monoxide Alarm (Amendment) Regulations 2022 are now in force and, as of 1 October 2022, all private and social landlords must ensure: at least one smoke alarm is equipped on each storey of their homes where there is a room used as living accommodation; that a carbon monoxide alarm is equipped in any room used as living accommodation which contains a fixed combustion appliance (excluding gas cookers); and ensure smoke alarms and carbon monoxide alarms are repaired or replaced once informed and found that they are faulty.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
×
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 Consider research findings and determine what changes are necessary to reduce fire risks in specialised housing.
Verbatim wording from the response “The Government recognises that further evidence is required on the benefit of sprinklers and other additional fire protection measures in specialised housing and, to this end, we have a dedicated research workstream in place. I will consider future research findings in light of your concerns and the evidence heard at Mr Harfield’s inquest, so that we can consider what changes are necessary to reduce the risk of similar incidents in the future. We have commissioned future research that will inform us of the benefit of sprinklers over other policy options such as enhancing fire detection and alarms or additional fire compartmentation. This will generate up-to-date evidence to help us review current building regulation policy and inform future changes.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Insufficient evidence and definitions prevent extending sprinkler consultation requirements to extra care premises pending further research.
Verbatim wording from the response “The Government recognises that further evidence is required on the benefit of sprinklers and other additional fire protection measures in specialised housing and, to this end, we have a dedicated research workstream in place. I will consider future research findings in light of your concerns and the evidence heard at Mr Harfield’s inquest, so that we can consider what changes are necessary to reduce the risk of similar incidents in the future. We have commissioned future research that will inform us of the benefit of sprinklers over other policy options such as enhancing fire detection and alarms or additional fire compartmentation. This will generate up-to-date evidence to help us review current building regulation policy and inform future changes.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing buildings are governed by fire risk assessments requiring responsible persons to provide adequate and appropriate fire precautions.
Verbatim wording from the response “Sprinklers in existing buildings
Fire safety in existing buildings is covered by separate legislation which includes the Regulatory Reform (Fire Safety) Order 2005 (the FSO). The FSO, which is the responsibility of the Home Office, applies to the common parts of multi-occupied residential buildings and requires the responsible person (the person in control of the premises – usually the building owner, landlord or managing agent) to undertake and review regularly a fire risk assessment. The responsible person must then ensure that adequate and appropriate fire precautions that mitigate against the risk to life from fire are in place. It is for the responsible person to determine these measures, based on the fire risk assessment.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsible persons, usually building owners, landlords or managing agents, must determine fire safety measures for existing buildings.
Verbatim wording from the response “Sprinklers in existing buildings
Fire safety in existing buildings is covered by separate legislation which includes the Regulatory Reform (Fire Safety) Order 2005 (the FSO). The FSO, which is the responsibility of the Home Office, applies to the common parts of multi-occupied residential buildings and requires the responsible person (the person in control of the premises – usually the building owner, landlord or managing agent) to undertake and review regularly a fire risk assessment. The responsible person must then ensure that adequate and appropriate fire precautions that mitigate against the risk to life from fire are in place. It is for the responsible person to determine these measures, based on the fire risk assessment.” Source location Response from Department for Levelling Up, Housing and Communities
Open published response
Concerns raised 6 Failure to rectify recognised disrepair without waiting for claimant agreement View source Lack of consideration of damp and mould in housing standards guidance View source Lack of easily accessible up-to-date health information on damp and mould risks View source Failure of the damp and mould HHSRS risk assessment data to reflect current known health risks View source Lack of private landlord sector access to independent Housing Ombudsman complaint investigation View source Lack of guidance on adequate property ventilation View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Awaab Ishak · 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
Awaab Ishak died on 21 December 2020 at the Royal Oldham Hospital, aged two, following a severe respiratory condition associated with prolonged exposure to mould in his home. The report identifies concerns about inadequate guidance and risk assessment for damp and mould, limited access to up-to-date health information, delays in addressing recognised disrepair where legal claims were ongoing, and the lack of independent complaints investigation for private landlords.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure to rectify recognised disrepair without waiting for claimant agreement
Wider context from the report “4. The evidence highlighted a “policy” amongst the housing associations , in cases where a disrepair claim has been brought of waiting for agreement from the claimant (or their legal representative) before rectifying any recognised disrepair .
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of consideration of damp and mould in housing standards guidance
Wider context from the report “1. The 2006 document, “A Decent Home: Definition and Guidance for Implementation” does not give any consideration to the issue of damp and mould . Nor does it provide any guidance as to the need for a property to be adequately ventilated.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of easily accessible up-to-date health information on damp and mould risks
Wider context from the report “3. There was no evidence that up to date relevant health information pertaining to the risks of damp and mould was easily accessible to the housing sector .
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Failure of the damp and mould HHSRS risk assessment data to reflect current known health risks
Wider context from the report “2. The HHSRS data sheet relating to damp and mould, is used to calculate risks of the incident and the spread of harm is not reflective of the current known risks of damp and mould and harm to health .
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of private landlord sector access to independent Housing Ombudsman complaint investigation
Wider context from the report “5. The private landlord sector does not have access to the Housing Ombudsman for their complaints to be investigated independently .
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on adequate property ventilation
Wider context from the report “1. The 2006 document, “A Decent Home: Definition and Guidance for Implementation” does not give any consideration to the issue of damp and mould. Nor does it provide any guidance as to the need for a property to be adequately ventilated .
” Open source report
×
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 Bring in reforms enhancing social housing regulation and redress to hold landlords accountable for housing quality and service.
Verbatim wording from the response “I am more determined than ever to deliver our drastic reforms to the housing sector, protecting the rights of tenants and ensuring social landlords do not put people’s lives and livelihoods at risk. Our Social Housing Regulation Bill will enable a rigorous new regime that holds all landlords to account for the decency of their homes and the service they provide. The Regulator of Social Housing will proactively inspect landlords – and will have the power to issue unlimited fines. It will be able to intervene in those cases where tenants’ lives are being put at risk because landlords are dragging their feet in actioning repairs. And in the very worst cases, it will have the power to instruct that properties are brought under new management.” Source location Response from Secretary of State for Levelling Up, Housing and Communities letter to All Providers for Social Housing
Open published response
×
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 Direct local housing authorities to prioritise damp and mould hazards and provide assessments of hazards and identified remedial action.
Verbatim wording from the response “Having considered it necessary and urgent to ensure that, as we go into a challenging winter, damp and mould issues are being addressed, I now direct, under section 3(3) of the Act, that all local housing authorities in carrying out their duty to review housing conditions in their area must:” Source location Response from Secretary of State for Levelling Up, Housing and Communities letter to Local Authority CE
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Social landlords are responsible for assessing damp and mould, undertaking necessary remedial action, and referring potential regulatory breaches.
Verbatim wording from the response “The coroner’s report into Awaab’s death is a litany of failure. As housing providers, I expect you to read it in full and absorb its lessons. All social homes must meet the Decent Homes Standard; you must be aware of any that do not and undertake rapid remedial works. However, in light of this case I expect you to go further than the letter of the Standard and have particular regard to damp and mould.¹ Damp and mould are not ‘lifestyle issues’ as the Housing Ombudsman Service underscored last year. Where people complain about damp and mould, you must listen; where you find them, you must take prompt action. To keep tenants safe, you must not hide behind legal process.” Source location Response from Secretary of State for Levelling Up, Housing and Communities letter to All Providers for Social Housing
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Regulator of Social Housing is responsible for proactively inspecting landlords and intervening where landlords fail to address risks to tenants.
Verbatim wording from the response “The Regulator of Social Housing will be writing to you imminently on this and you should respond promptly. You should also self-refer to the Regulator of Social Housing should you become aware through those assessments, or other means, that you may be in breach of its regulatory standards.” Source location Response from Secretary of State for Levelling Up, Housing and Communities letter to All Providers for Social Housing
Open published response
Concerns raised 3 Lack of colour coding of gas cylinders for emergency-service identification View source Lack of licensing controls for public purchase or acquisition of gas canisters View source Insufficient clarity and adequacy of gas canister safety information View source
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
David Honnor · 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
David Honnor had oesophageal cancer and underwent radiotherapy and stent placement before his condition worsened in 2022. He obtained a gas canister and died from asphyxia; the inquest recorded suicide. Concerns included public access to these products, whether they should be licensed, the lack of colour coding to help emergency services identify gas cylinders, and whether safety information was clear and sufficient.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of colour coding of gas cylinders for emergency-service identification
Wider context from the report “2. I have concerns with regard to the following:
i. I have concerns that members of the public are able to purchase or acquire ████████.
ii. I have concerns that these products should be licensed.
iii. I have concerns that there is no colour coding of gas cylinders to assist first response emergency services .
iv. I have concerns as to whether the safety information on these gas cannisters is clear and sufficient.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of licensing controls for public purchase or acquisition of gas canisters
Wider context from the report “2. I have concerns with regard to the following:
i. I have concerns that members of the public are able to purchase or acquire ████████ .
ii. I have concerns that these products should be licensed .
iii. I have concerns that there is no colour coding of gas cylinders to assist first response emergency services.
iv. I have concerns as to whether the safety information on these gas cannisters is clear and sufficient.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Insufficient clarity and adequacy of gas canister safety information
Wider context from the report “2. I have concerns with regard to the following:
i. I have concerns that members of the public are able to purchase or acquire ████████.
ii. I have concerns that these products should be licensed.
iii. I have concerns that there is no colour coding of gas cylinders to assist first response emergency services.
iv. I have concerns as to whether the safety information on these gas cannisters is clear and sufficient .
” Open source report
Concerns raised 2 Lack of mandatory sprinkler system requirements for care homes housing occupants with limited or no independent mobility View source Exclusion of care homes housing occupants with limited or no independent mobility from Higher Risk Building designation below height or storey thresholds View source
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
Daphne Holloway and Ivy Spriggs · 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
Daphne Holloway and Ivy Spriggs died in a fire at Newgrange Residential Care Home on 8 April 2017. The fire spread rapidly because of inadequate roofspace compartmentation, and both residents died from fourth degree burns. Concerns were raised that sprinklers are not mandatory in care homes with residents who have limited or no independent mobility, and that such care homes are not classified as Higher Risk Buildings unless they meet height or storey thresholds.
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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory sprinkler system requirements for care homes housing occupants with limited or no independent mobility
Wider context from the report “(1) That sprinkler systems are not a mandatory requirement for care homes whose occupants have either limited or no independent mobility and are therefore at higher risk from fire.
” 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 Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Exclusion of care homes housing occupants with limited or no independent mobility from Higher Risk Building designation below height or storey thresholds
Wider context from the report “(2) That care homes whose occupants have either limited or no independent mobility, and are therefore at higher risk from fire, are not deemed to be ‘Higher Risk Buildings’ unless they are at least 18m in height or at least 7 storeys high .
” Open source report
Pin
Request correction
Addressed to Ministry of Housing, Communities & Local Government (2018 to 2021), now represented here by Ministry of Housing, Communities and Local Government.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations