Concerns raised 3 Lack of guidance on management and escalation of fire risk in supported accommodation View source Failure of smoke detection systems to provide sufficiently early warning of cigarette-related fires View source Lack of statutory requirement for sprinkler systems in supported accommodation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Golds · 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
James Golds was rescued from a flat fire on 28 September 2020 after sustaining significant fire-related injuries and later died in hospital from complications of smoke inhalation. The report raised concerns about limited guidance for managing and escalating fire risks in supported accommodation, the absence of a statutory requirement for sprinklers, and smoke detectors not activating until a cigarette-related fire was well established.
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 guidance on management and escalation of fire risk in supported accommodation
Wider context from the report “1. From the evidence before the court it was clear that Mr Golds presented a significant risk of accidentally starting a fire. He resided in accommodation occupied by vulnerable members of the community who needed some support to live independently. The Court heard that there was little guidance for facilities such as his about how the risk of fire should be managed and escalation of such risk .
” 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 smoke detection systems to provide sufficiently early warning of cigarette-related fires
Wider context from the report “2. In addition in relation to the design and fire prevention features for such accommodation the inquest heard that there was no statutory requirement for sprinkler systems. Smoke detectors were in the hallway areas of each flat but because of the way in which a cigarette related fire developed the detector would not be triggered until the fire was well established . This made it difficult to escape and increase the risk of the fire spreading further .
” 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 statutory requirement for sprinkler systems in supported accommodation
Wider context from the report “2. In addition in relation to the design and fire prevention features for such accommodation the inquest heard that there was no statutory requirement for sprinkler systems . Smoke detectors were in the hallway areas of each flat but because of the way in which a cigarette related fire developed the detector would not be triggered until the fire was well established. This made it difficult to escape and increase the risk of the fire spreading further.
” 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 technical review of Approved Document B, including evidence research and review of provisions for new specialised housing and care homes.
Verbatim wording from the response “Regarding sprinklers specifically, in November 2020 the Government brought forward changes to the guidance to the Building Regulations with regards to fire safety (Approved Document B) reducing the height threshold at which sprinkler systems are provided in new blocks of flats from 30 metres to 11 metres and greatly increased the number of future homes provided with sprinkler protection. This was the first step in a full technical review of Approved Document B, which will include research to ensure that any changes to this guidance is based on a robust evidence base. The technical review programme includes a workstream reviewing the current provisions for new specialised housing and care homes such as the one in which Mr Golds resided.” Source location 2021-0284-Response-from-Department-for-Levelling-Up-Housing-Communities_Published.pdf
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 Mandatory sprinklers are not required universally because existing risk-based controls and ongoing reviews tailor fire protection to individual buildings and residents.
Verbatim wording from the response “Regarding sprinklers specifically, in November 2020 the Government brought forward changes to the guidance to the Building Regulations with regards to fire safety (Approved Document B) reducing the height threshold at which sprinkler systems are provided in new blocks of flats from 30 metres to 11 metres and greatly increased the number of future homes provided with sprinkler protection. This was the first step in a full technical review of Approved Document B, which will include research to ensure that any changes to this guidance is based on a robust evidence base. The technical review programme includes a workstream reviewing the current provisions for new specialised housing and care homes such as the one in which Mr Golds resided.” Source location 2021-0284-Response-from-Department-for-Levelling-Up-Housing-Communities_Published.pdf
Open published response
2 Jul 2021 Henry Boddy · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Gap in enforcement powers for addressing fire risks from hoarding-related fire loads in residential 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
Henry Boddy · 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
Henry Boddy was found collapsed during a significant fire at his home on 4 November 2020 and died later that day from the consequences of the fire. The fire was later found to have been caused by either unsafe use of candles for lighting or unsafe use or disposal of smoking materials, in the context of longstanding hoarding and an accumulated fire load. The principal concern was a gap in enforcement powers for addressing fire risks in residential properties arising from hoarding behaviour.
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 Gap in enforcement powers for addressing fire risks from hoarding-related fire loads in residential properties
Wider context from the report “I am aware that the Government has recently consultant on and responded to potential additional fire safety measures. However, from the evidence I heard at this inquest and from my review of the Government’s response, I am concerned that there is a gap in enforcement powers, as they relate to addressing fire risks in residential properties; specifically in this circumstance, the risks of a fire load arising from hoarding behaviour .
” Open source report
Concerns raised 3 Potential fire hazards in properties managed by the same property managers, including inadequate smoke detection equipment or emergency escape routes View source Failure to ascertain housing safety and regulatory approval before awarding Local Housing Allowance View source Lack of periodic checking and replacement of smoke detection devices View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Philip Noel Sheridan · 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
Philip Noel Sheridan suffered smoke inhalation and subsequently died after a fire on 26 June 2019 in the cellar flat where he lived. The flat had no smoke detector, had a single exit door without a handle positioned next to the fire, and had not received relevant planning, building-regulation, or housing inspection approval. Concerns included potential fire hazards in other properties, the processing of Local Housing Allowance without establishing safety, and the absence of an ongoing requirement to check that smoke alarms remained effective.
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 Potential fire hazards in properties managed by the same property managers, including inadequate smoke detection equipment or emergency escape routes
Wider context from the report “1) ████████ entered an Assured Shorthold Tenancy Agreement with the deceased on 14th August 2013. He was a person in control of the cellar flat within the meaning defined in the Housing Act 2004. He and/or ████████ were involved in the management of other properties in the Leeds area in the period 2013-2019. He or they should have been aware that the cellar flat did not have planning consent, Building Regulation Approval and had not been inspected by Leeds City Council Housing Officers. The evidence taken at the Inquest gave rise to a concern on the balance of probability that the hazards identified in the cellar flat may be replicated in other properties managed by them, particularly in relation to the provision of smoke detection equipment or emergency escape routes in the event of 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 Failure to ascertain housing safety and regulatory approval before awarding Local Housing Allowance
Wider context from the report “2) Leeds City Council made payments relating to Local Housing Allowance direct to ████████ totalling £9462.05 in respect of the cellar flat which had taken the address of ████████ Leeds. This was done without ascertaining whether the cellar flat had planning consent, Building Regulation Approval or had been inspected by Leeds City Council Housing Officers to establish whether it was safe for human habitation. Evidence taken at the Inquest indicated there were many other comparable properties in Leeds. This situation gives rise to a concern that fire hazards may be present in respect of properties which may have the appearance of being approved by virtue of the award of Local Housing Allowance.
” 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 periodic checking and replacement of smoke detection devices
Wider context from the report “3) Evidence taken at the Inquest indicated that whilst a Landlord has an obligation to provide smoke detection devices at the inception of a tenancy, there was no ongoing duty to ensure they continued to be effective or replace them if found to be faulty . In this case the tenant had resided in a cellar flat for nearly six years, before he sustained injuries in a fire which proved fatal. There was no smoke alarm in the cellar flat at the time of the fire on 26th June 2019.
I am concerned that the laudable statutory objective enshrined in The Smoke and Carbon Monoxide Alarm (England) Regulations 2015 is undermined if a landlord is not required to check periodically such devices are still effective.
” 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 Analyse responses to the smoke and carbon-monoxide alarm regulations consultation.
Verbatim wording from the response “We are also proposing to amend the legislation to create an obligation for social and private landlords to repair or replace smoke alarms, once informed that they are faulty. We are not proposing to require landlords to test smoke alarms throughout the life of a tenancy. The consultation ran for 8 weeks from 17 November 2020 and closed on 11 January 2021. We are currently analysing the responses and will publish our response in due course.” Source location 2021-0016-Response-from-Ministry-of-Housing-Communities-Local-Government-Redacted
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 Examine ways to support increased planning-enforcement activity.
Verbatim wording from the response “As part of our reform of the planning system, we are keen to see a stronger emphasis on planning enforcement. Our recent ‘Planning for the Future’ White Paper sets out our intention to introduce stronger enforcement powers and to look at ways of supporting more enforcement activity.” Source location 2021-0016-Response-from-Ministry-of-Housing-Communities-Local-Government-Redacted
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 the Government response to the smoke and carbon-monoxide alarm regulations consultation.
Verbatim wording from the response “We are also proposing to amend the legislation to create an obligation for social and private landlords to repair or replace smoke alarms, once informed that they are faulty. We are not proposing to require landlords to test smoke alarms throughout the life of a tenancy. The consultation ran for 8 weeks from 17 November 2020 and closed on 11 January 2021. We are currently analysing the responses and will publish our response in due course.” Source location 2021-0016-Response-from-Ministry-of-Housing-Communities-Local-Government-Redacted
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 Introduce stronger planning-enforcement powers through planning-system reform.
Verbatim wording from the response “As part of our reform of the planning system, we are keen to see a stronger emphasis on planning enforcement. Our recent ‘Planning for the Future’ White Paper sets out our intention to introduce stronger enforcement powers and to look at ways of supporting more enforcement activity.” Source location 2021-0016-Response-from-Ministry-of-Housing-Communities-Local-Government-Redacted
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 Fund production of planning-enforcement guidance for local authorities.
Verbatim wording from the response “Day to day responsibility for planning control rests with local planning authorities. We have recently funded the National Association of Planning Enforcement (NAPE) to produce guidance to help authorities carry out their enforcement functions. This guidance sets out the wide range of powers available and provides advice about their use in practice. In particular, local authorities have various powers to request information about the ownership and use of land. NAPE’s guidance contains examples of sources of information that authorities may draw upon, including things such as housing and council tax records.” Source location 2021-0016-Response-from-Ministry-of-Housing-Communities-Local-Government-Redacted
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 Consult on extending smoke and carbon-monoxide alarm requirements to social housing.
Verbatim wording from the response “We are currently consulting on proposals to extend the Smoke and Carbon Monoxide Alarm (England) Regulations 2015. We are proposing to mandate smoke alarms in all socially rented homes. Social landlords would be obliged to provide a smoke alarm on each storey of the premises on which there is a room used wholly or partly as living accommodation. This would bring requirements in line with those for private landlords.” Source location 2021-0016-Response-from-Ministry-of-Housing-Communities-Local-Government-Redacted
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 Day-to-day responsibility for planning control rests with local planning authorities, rather than central government.
Verbatim wording from the response “Day to day responsibility for planning control rests with local planning authorities. We have recently funded the National Association of Planning Enforcement (NAPE) to produce guidance to help authorities carry out their enforcement functions. This guidance sets out the wide range of powers available and provides advice about their use in practice. In particular, local authorities have various powers to request information about the ownership and use of land. NAPE’s guidance contains examples of sources of information that authorities may draw upon, including things such as housing and council tax records.” Source location 2021-0016-Response-from-Ministry-of-Housing-Communities-Local-Government-Redacted
Open published response
Concerns raised 3 Failure to update the WDRP practical guide to address food allergy deaths View source Delays in notifying food allergy fatalities to relevant food-safety oversight functions View source Absence of a national process and register for food allergy deaths 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
Master Ruben Bousquet · 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
Master Ruben Bousquet died after consuming popcorn that had become cross-contaminated with milk protein, causing acute anaphylaxis. The report raised concerns about timely sharing and registration of fatal food-allergy incidents, and about whether food businesses should have access to adrenaline auto-injectors.
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 update the WDRP practical guide to address food allergy deaths
Wider context from the report “1. Reporting and Registering
The Head of Incidents at the FSA informed the court that the FSA has started work on a reporting platform for allergic reactions, but needs access to information on all fatalities if it is to have effective oversight of food safety. It would welcome improved appropriate sharing of information on fatalities as they are not routinely notified in a timely manner when there is a report of a fatality by the local authority or coroner.
The Team Leader of Environmental Health in Royal Borough of Greenwich gave evidence that in 2019 the national Work Related Deaths Committee accepted a recommendation that the practical guide of the WDRP should be updated to address concerns surrounding food allergy deaths and the HSE is considering an amendment, but it has not yet been possible to take this forward .
The Head of Trading Standards at the Royal London Borough of Greenwich confirmed that there was no national register (the subject of a PFD report from this jurisdiction in November 2019), but stressed that it is not the HSE who investigates these deaths and that a national process was needed that involved the local authorities coroners and FSA.
” 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 notifying food allergy fatalities to relevant food-safety oversight functions
Wider context from the report “1. Reporting and Registering
The Head of Incidents at the FSA informed the court that the FSA has started work on a reporting platform for allergic reactions, but needs access to information on all fatalities if it is to have effective oversight of food safety . It would welcome improved appropriate sharing of information on fatalities as they are not routinely notified in a timely manner when there is a report of a fatality by the local authority or coroner.
The Team Leader of Environmental Health in Royal Borough of Greenwich gave evidence that in 2019 the national Work Related Deaths Committee accepted a recommendation that the practical guide of the WDRP should be updated to address concerns surrounding food allergy deaths and the HSE is considering an amendment, but it has not yet been possible to take this forward.
The Head of Trading Standards at the Royal London Borough of Greenwich confirmed that there was no national register (the subject of a PFD report from this jurisdiction in November 2019), but stressed that it is not the HSE who investigates these deaths and that a national process was needed that involved the local authorities coroners and FSA.
” 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 Absence of a national process and register for food allergy deaths
Wider context from the report “1. Reporting and Registering
The Head of Incidents at the FSA informed the court that the FSA has started work on a reporting platform for allergic reactions, but needs access to information on all fatalities if it is to have effective oversight of food safety. It would welcome improved appropriate sharing of information on fatalities as they are not routinely notified in a timely manner when there is a report of a fatality by the local authority or coroner.
The Team Leader of Environmental Health in Royal Borough of Greenwich gave evidence that in 2019 the national Work Related Deaths Committee accepted a recommendation that the practical guide of the WDRP should be updated to address concerns surrounding food allergy deaths and the HSE is considering an amendment, but it has not yet been possible to take this forward.
The Head of Trading Standards at the Royal London Borough of Greenwich confirmed that there was no national register (the subject of a PFD report from this jurisdiction in November 2019), but stressed that it is not the HSE who investigates these deaths and that a national process was needed that involved the local authorities coroners and FSA .
” Open source report
Concerns raised 1 Lack of statutory requirements for the Code of Practice and British Standard 5839 LD1 Maximum Protection level 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
John Joseph Jennings · 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
John Joseph Jennings died at home from smoke inhalation during a fire on 18 October 2019, before the London Fire Brigade arrived. Concerns were raised that relevant alarm-monitoring and fire-detection standards were not statutory requirements.
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 statutory requirements for the Code of Practice and British Standard 5839 LD1 Maximum Protection level
Wider context from the report “1. Evidence was heard expressing concern that the above Code of Practice and British Standard 5839 LD1 Maximum Protection level were not currently statutory requirements .
” Open source report
Concerns raised 2 Lack of residential landlord inspection of window coverings at private rental properties View source Failure of residential landlords to ensure the use of safety cords on blinds in rental properties View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joey Jenson Walker · 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
Joey Jenson Walker was found unresponsive after becoming entangled by the neck in a roller-blind cord and died 18 days later in hospital. The report expressed concern that residential landlords were not required to inspect window coverings or ensure that only safety cords were used in privately rented properties.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Housing, Communities and Local Government; that does not assign responsibility.
PFD Monitor interpretation Lack of residential landlord inspection of window coverings at private rental properties
Wider context from the report “It is a matter of concern that residential landlords are not currently subject to any obligation to inspect window coverings such as roller blinds installed at private rental properties , or to otherwise ensure that only safety cords are used on blinds in use in properties let out to residential tenants.
” 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 residential landlords to ensure the use of safety cords on blinds in rental properties
Wider context from the report “It is a matter of concern that residential landlords are not currently subject to any obligation to inspect window coverings such as roller blinds installed at private rental properties, or to otherwise ensure that only safety cords are used on blinds in use in properties let out to residential tenants .
” 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 Identify additional ways to disseminate blind-cord safety information across all housing tenures.
Verbatim wording from the response “My officials have worked with their colleagues at OPSS to further publicise this campaign, through our newsletters to landlords and local authorities and our suite of guides for private rented sector landlords and tenants that cover safety in rented properties. I will ask that they continue this work with their colleagues in OPSS, in particular identifying more ways this information can be disseminated to all housing tenures.” Source location 2020-0226-Response-from-Secretary-of-State-for-Housing-Communities-and-Local-Government-REDACTED.pdf
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 Publicise the blind-cord safety campaign through newsletters to landlords and local authorities and private rented-sector landlord and tenant guides.
Verbatim wording from the response “My officials have worked with their colleagues at OPSS to further publicise this campaign, through our newsletters to landlords and local authorities and our suite of guides for private rented sector landlords and tenants that cover safety in rented properties. I will ask that they continue this work with their colleagues in OPSS, in particular identifying more ways this information can be disseminated to all housing tenures.” Source location 2020-0226-Response-from-Secretary-of-State-for-Housing-Communities-and-Local-Government-REDACTED.pdf
Open published response
13 Sep 2019 Lucia Jayne Stear · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1 Failure of public authorities to address tree safety concerns before a fatal event View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lucia Jayne Stear · 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
Lucia Jayne Stear was born after a large tree bough fell onto her pregnant mother's car on Arrowe Park Road, causing abdominal trauma. Lucia was delivered by emergency caesarean section, developed multi-organ failure, and died at 15 hours old. The inquest identified inadequate tree management, inspection, training, risk assessment, accountability and communication by Wirral Borough Council, and raised concerns about whether other public authorities faced similar risks.
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 of public authorities to address tree safety concerns before a fatal event
Wider context from the report “Before the inquest Wirral MBC put in place a “Tree Action Plan” which is address the concerns that had been before the court – This is included as an example of what can be achieved when this problem was highlighted by the death of a 15 hour old resident of the Borough.
How many other public authorities are in a similar plight, not having had a fatal tragic event to prompt action?
The Court asks the Rt. Hon. Secretary of State to address this issue nationally and that he advises the court as to what steps he has directed to be taken to ensure that there is national learning from Lucia’s short life and her tragic avoidable death.
The Court requests that the LGA brings this matter to the attention of its Local Authority members and that the LGA advises the court as to what steps the organisation has taken to ensure that there is national learning from Lucia’s short life and her tragic avoidable death
” 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 spending on parks, including responding to the concern, lies with local authorities.
Verbatim wording from the response “You have asked for action to be taken nationally, to stop such an accident happening again. Spending on parks is a matter for local authorities. We acknowledge that local authorities are working under financial pressure, that’s why this year the Chancellor has announced the biggest year-on-year real terms increase in spending power for local government in almost a decade. Core Spending Power (CSP) is expected to rise from £46.2 billion to £49.1 billion in 2020-21, an estimated 4.3% real terms increase.” Source location 2019-0296-Response-by-Ministry-of-Housing-Communities-Local-Government
Open published response
Concerns raised 1 Lack of national oversight, guidance and support for private landlords on safety regulations 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
Macy May Barbara Fletcher · 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
Macy May Barbara Fletcher, a two-year-old child, was found unresponsive at home on 9 January 2019 with a blind cord strangulating her neck and died later that day in hospital. The blind had been fitted before 2014 and had no safety features. The report raised concerns about the lack of oversight and guidance for private landlords regarding updated blind-safety regulations, and the risks posed by older blinds to young 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 national oversight, guidance and support for private landlords on safety regulations
Wider context from the report “During the course of the inquest I heard evidence that there is no national body to provide oversight and offer guidance and support to private landlords on their legal obligations and responsibilities and to share best practice – specifically in relation to updates in safety regulations . This would be of benefit to tenants, landlords and would assist in preventing future fatalities
” Open source report
Concerns raised 1 Lack of mandatory BS7671 inspection of electrical installations in the private rental sector View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Charles Alliston · 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
John Charles Alliston was found deceased in the garden of his private rental property on 8 June 2017 after sustaining a fatal electric shock from a live capillary wire associated with the oil heating system. The report raised concerns that private rental electrical installations were not mandatorily inspected to BS7671, leaving a risk of further deaths while the timing of new legislation remained unclear.
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 BS7671 inspection of electrical installations in the private rental sector
Wider context from the report “Currently there is no mandatory requirement for electrical installations in the private rental sector to be inspected to the requirements of BS7671. I acknowledge that legislation is due to be coming into force. However it remains unclear when this is going to occur. In the meantime, there remains a risk of further deaths occurring.
” 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 regulations into force requiring private rented sector landlords to arrange electrical installation inspections at least every five years, subject to parliamentary approval and timetable.
Verbatim wording from the response “We recognise, however, that we must go further. As you are already aware, on 19 July 2018 we announced that we will introduce a mandatory requirement on landlords in the private rented sector to ensure electrical installations in their property are inspected at least every five years, to ensure they meet the electrical safety standards introduced by the Regulations.” Source location 2019-0153-Response-by-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 Bringing mandatory electrical safety regulations into force is subject to parliamentary approval and the parliamentary timetable.
Verbatim wording from the response “Please be assured that this is a matter of paramount importance to me, and my Department is working to bring regulations into force as soon as possible, subject to parliamentary approval and timetable.” Source location 2019-0153-Response-by-Ministry-of-Housing-Communities-Local-Government
Open published response
22 Mar 2019 Bram Luke Radcliffe · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 3 Failure to ensure safe installation of fireplace surrounds View source Lack of a British Standard for fixing stone fireplace surrounds View source Exclusion of fire surround provision from Building Regulations 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
Bram Luke Radcliffe · 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 8 November 2017, two-year-old Bram Luke Radcliffe was found unresponsive after a marble fireplace surround detached from the wall and struck him. He was taken to hospital but died later that morning from his head injury. Evidence at the inquest indicated that the fireplace surround installation was substandard and dangerous, and raised concerns about the absence of a British Standard for fixing stone fireplace surrounds and their exclusion from building regulations.
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 safe installation of fireplace surrounds
Wider context from the report “During the inquest I heard evidence to indicate that the installation of the fireplace surround was both substandard and dangerous , and that there is currently no British Standard for the fixing of stone fireplace surrounds only for the manufacture. I was informed that the provision of a fire surround is not ‘building work’ as defined by Regulation 3(1) of the Building Regulations 2010 (as amended), therefore would not be the subject to Building Regulations and subject to guidance provided by the manufacturer/supplier and good building practice.
” 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 a British Standard for fixing stone fireplace surrounds
Wider context from the report “During the inquest I heard evidence to indicate that the installation of the fireplace surround was both substandard and dangerous, and that there is currently no British Standard for the fixing of stone fireplace surrounds only for the manufacture . I was informed that the provision of a fire surround is not ‘building work’ as defined by Regulation 3(1) of the Building Regulations 2010 (as amended), therefore would not be the subject to Building Regulations and subject to guidance provided by the manufacturer/supplier and good building practice.
” 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 fire surround provision from Building Regulations
Wider context from the report “During the inquest I heard evidence to indicate that the installation of the fireplace surround was both substandard and dangerous, and that there is currently no British Standard for the fixing of stone fireplace surrounds only for the manufacture. I was informed that the provision of a fire surround is not ‘building work’ as defined by Regulation 3(1) of the Building Regulations 2010 (as amended), therefore would not be the subject to Building Regulations and subject to guidance provided by the manufacturer/supplier and good building practice.
” Open source report
Concerns raised 6 Failure to maintain originally provided fire safety measures, including the kitchen door View source Failure to upgrade existing maisonettes in line with fire safety best-practice guidance View source Insufficient housing-sector awareness of fire risks from inadequate detection and escape protection View source Inadequate design of alternative means of escape from upper floors of maisonettes View source Failure to adopt relevant fire safety guidance for purpose-built blocks of flats View source Absence of functioning fire detection and warning in maisonette halls or landings View source See 3 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
Ms Mihaela Lazar and Ms Dorina Zangari · 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
Ms Mihaela Lazar and Ms Dorina Zangari died after a fire at their home on 25 January 2017, probably started by clothing overlying a heater, and they were overcome by fire fumes before escaping. Concerns included inadequate fire detection and warning, the lack of a protected means of escape from the upper floor, and missing fire safety measures such as a kitchen door.
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 maintain originally provided fire safety measures, including the kitchen door
Wider context from the report “1. The maisonette in which Dorina Zangari and Michaela Lazar lived was let for use as a single private dwelling. As it happened, it was being used as a House in Multiple Occupation, but the fire safety issues of concern to LFB relate to any maisonette used as a single family dwelling. The lack of early detection and warning of fire (i.e. the provision of smoke alarms) and a protected means of escape from the upper floor of the maisonette (which was at too high a level for escape by windows) contributed to the occupants being unable to escape from the fire.
The problem is threefold:-
i) Undermining of the originally provided fire safety measures i.e. missing kitchen door
ii) Absence of functioning fire detection and warning in the hall or landing, which was not required at the time of construction of the block of flats but, at the time of the fire, was a statutory requirement both for flats in single family occupation and multiple occupation; and
iii) The design of the alternative means of escape, which comprised the balcony on the upper level of the maisonette, shared with the next door maisonette. This was acceptable at the time of construction but this is not acceptable today (without additional measures such as smoke alarms in every room) as this will involve breaking in to a neighbours flat.
There are many thousands of these types of maisonette across the country which have not been upgraded using options in line with best practice guidance (see below) and this is leaving people at a significant risk of death or injury 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 Failure to upgrade existing maisonettes in line with fire safety best-practice guidance
Wider context from the report “1. The maisonette in which Dorina Zangari and Michaela Lazar lived was let for use as a single private dwelling. As it happened, it was being used as a House in Multiple Occupation, but the fire safety issues of concern to LFB relate to any maisonette used as a single family dwelling. The lack of early detection and warning of fire (i.e. the provision of smoke alarms) and a protected means of escape from the upper floor of the maisonette (which was at too high a level for escape by windows) contributed to the occupants being unable to escape from the fire.
The problem is threefold:-
i) Undermining of the originally provided fire safety measures i.e. missing kitchen door
ii) Absence of functioning fire detection and warning in the hall or landing, which was not required at the time of construction of the block of flats but, at the time of the fire, was a statutory requirement both for flats in single family occupation and multiple occupation; and
iii) The design of the alternative means of escape, which comprised the balcony on the upper level of the maisonette, shared with the next door maisonette. This was acceptable at the time of construction but this is not acceptable today (without additional measures such as smoke alarms in every room) as this will involve breaking in to a neighbours flat.
There are many thousands of these types of maisonette across the country which have not been upgraded using options in line with best practice guidance (see below) and this is leaving people at a significant risk of death or injury 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 Insufficient housing-sector awareness of fire risks from inadequate detection and escape protection
Wider context from the report “3. Recommendations
London Fire Brigade believes that stakeholders within the housing sector are not sufficiently aware of the risk of death or injury associated with inadequate fire detection and alarm systems and inadequate protection of the means of escape within the flat , in the event of a fire, presented by this type of premises. Consequently they have not adopted the guidance and recommendations in the Local Government Association publication 'Fire safety in purpose-built blocks of flats'.
” 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 design of alternative means of escape from upper floors of maisonettes
Wider context from the report “1. The maisonette in which Dorina Zangari and Michaela Lazar lived was let for use as a single private dwelling. As it happened, it was being used as a House in Multiple Occupation, but the fire safety issues of concern to LFB relate to any maisonette used as a single family dwelling. The lack of early detection and warning of fire (i.e. the provision of smoke alarms) and a protected means of escape from the upper floor of the maisonette (which was at too high a level for escape by windows) contributed to the occupants being unable to escape from the fire.
The problem is threefold:-
i) Undermining of the originally provided fire safety measures i.e. missing kitchen door
ii) Absence of functioning fire detection and warning in the hall or landing, which was not required at the time of construction of the block of flats but, at the time of the fire, was a statutory requirement both for flats in single family occupation and multiple occupation; and
iii) The design of the alternative means of escape, which comprised the balcony on the upper level of the maisonette, shared with the next door maisonette. This was acceptable at the time of construction but this is not acceptable today (without additional measures such as smoke alarms in every room) as this will involve breaking in to a neighbours flat.
There are many thousands of these types of maisonette across the country which have not been upgraded using options in line with best practice guidance (see below) and this is leaving people at a significant risk of death or injury 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 Failure to adopt relevant fire safety guidance for purpose-built blocks of flats
Wider context from the report “3. Recommendations
London Fire Brigade believes that stakeholders within the housing sector are not sufficiently aware of the risk of death or injury associated with inadequate fire detection and alarm systems and inadequate protection of the means of escape within the flat, in the event of a fire, presented by this type of premises. Consequently they have not adopted the guidance and recommendations in the Local Government Association publication 'Fire safety in purpose-built blocks of flats' .
” 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 Absence of functioning fire detection and warning in maisonette halls or landings
Wider context from the report “1. The maisonette in which Dorina Zangari and Michaela Lazar lived was let for use as a single private dwelling. As it happened, it was being used as a House in Multiple Occupation, but the fire safety issues of concern to LFB relate to any maisonette used as a single family dwelling. The lack of early detection and warning of fire (i.e. the provision of smoke alarms) and a protected means of escape from the upper floor of the maisonette (which was at too high a level for escape by windows) contributed to the occupants being unable to escape from the fire.
The problem is threefold:-
i) Undermining of the originally provided fire safety measures i.e. missing kitchen door
ii) Absence of functioning fire detection and warning in the hall or landing , which was not required at the time of construction of the block of flats but, at the time of the fire, was a statutory requirement both for flats in single family occupation and multiple occupation; and
iii) The design of the alternative means of escape, which comprised the balcony on the upper level of the maisonette, shared with the next door maisonette. This was acceptable at the time of construction but this is not acceptable today (without additional measures such as smoke alarms in every room) as this will involve breaking in to a neighbours flat.
There are many thousands of these types of maisonette across the country which have not been upgraded using options in line with best practice guidance (see below) and this is leaving people at a significant risk of death or injury from fire.
” Open source report
Concerns raised 3 Failure to ensure understanding of the meaning of countersigning risk assessment checklists View source Failure to seek medical or paramedic assistance when warranted by a person's condition View source Failure to address inaccuracies in moving and handling risk assessment checklists during investigations 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
Helen Theresa Cannon · 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
Helen Theresa Cannon fell at home on 2 April 2017 and was assisted from the floor by Eldercare emergency responders without medical or paramedic assistance being sought. She had suffered internal haemorrhage from a pelvic fracture sustained in the fall and died two days later; concerns were also identified about inaccuracies in the moving and handling risk assessment and flaws in Eldercare’s subsequent investigation.
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 understanding of the meaning of countersigning risk assessment checklists
Wider context from the report “2. Following Mrs Cannon’s death Eldercare carried out an investigation. The investigation was flawed in that it did not address clear inaccuracies in the Moving and Handling Risk assessment checklist completed by one of the Emergency Responders, nor did it discover that the other Emergency Responder attending did not understand that he was agreeing with the accuracy of the information recorded on the checklist when he countersigned it . It was his belief that he signed the checklist simply to agree that he had been present .
” 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 seek medical or paramedic assistance when warranted by a person's condition
Wider context from the report “1. The emergency responders did not seek medical or paramedic assistance for Mrs Cannon because she was complaining of suffering aching rather than pain . It transpired that Mrs Cannon had suffered internal haemorrhage as a result of a pelvic fracture sustained in her fall, and this led to her death two days later. Evidence was heard at the Inquest from a Consultant Trauma and Orthopaedic Surgeon that in the circumstances it would have been good practice to have obtained medical or paramedic assistance for Mrs Cannon .
” 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 address inaccuracies in moving and handling risk assessment checklists during investigations
Wider context from the report “2. Following Mrs Cannon’s death Eldercare carried out an investigation. The investigation was flawed in that it did not address clear inaccuracies in the Moving and Handling Risk assessment checklist completed by one of the Emergency Responders, nor did it discover that the other Emergency Responder attending did not understand that he was agreeing with the accuracy of the information recorded on the checklist when he countersigned it. It was his belief that he signed the checklist simply to agree that he had been present.
” Open source report
Concerns raised 5 Lack of regulatory oversight of stone fireplace manufacture View source Failure to regulate and control fireplace installation View source Lack of regulatory oversight of stone fireplace installation View source Inadequate specificity of fireplace installation instructions View source Lack of quality and safety standards for fireplaces View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Isabella Pritchard · 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
Isabella Pritchard, aged six, died from catastrophic head injuries after a marble mantelpiece in her home fell and struck her. The report raised concerns that fireplaces and their installation were unregulated, with no applicable quality or safety standard and potential dangers arising from design and inadequate fixing.
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 regulatory oversight of stone fireplace manufacture
Wider context from the report “(1) It appears to me that both the manufacturer and installation of stone fireplaces are an unregulated industry .
” 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 regulate and control fireplace installation
Wider context from the report “(3) I understand that there is no regulation or building control around the installation of fireplaces . I believe building regulations do not cover this area as they are deemed to be a decorative item. While I understand that the NHBC now mandatorily require the use of mechanical fixings, this does not cover every instance. Also, that the Stone Federation issued guidelines but are guidelines only. Further, they are a non-regulatory trade body where membership is optional and adherence to their guidelines is entirely voluntary .
” 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 regulatory oversight of stone fireplace installation
Wider context from the report “(1) It appears to me that both the manufacturer and installation of stone fireplaces are an unregulated industry .
” 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 specificity of fireplace installation instructions
Wider context from the report “(2) There appears to be no quality/safety standard that applies to fireplaces. The British Standards (BS1251) appears to relate purely to flues and combustible properties of the chimney itself. I am aware of no BSI kite mark applicable to fireplaces. It therefore seems possible to design and manufacture a product with dangerous design features that are cosmetically attractive but inherently dangerous. The fireplace that struck and killed Isabella Pritchard incorporated a stone mantel weighing 86kg with a design relying on gravity and adhesive to keep it in place. In addition, the installation instructions provided by the manufacturer by their own installer were vague in detail, generic and covered their whole range of products . I understand that most high street DIY warehouses sell fireplaces, some weighing as much as 125kg where the design, if untested, could have the same design faults.
” 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 quality and safety standards for fireplaces
Wider context from the report “(2) There appears to be no quality/safety standard that applies to fireplaces . The British Standards (BS1251) appears to relate purely to flues and combustible properties of the chimney itself. I am aware of no BSI kite mark applicable to fireplaces . It therefore seems possible to design and manufacture a product with dangerous design features that are cosmetically attractive but inherently dangerous. The fireplace that struck and killed Isabella Pritchard incorporated a stone mantel weighing 86kg with a design relying on gravity and adhesive to keep it in place. In addition, the installation instructions provided by the manufacturer by their own installer were vague in detail, generic and covered their whole range of products. I understand that most high street DIY warehouses sell fireplaces, some weighing as much as 125kg where the design, if untested, could have the same design faults.
” 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 Ask the Building Regulations Advisory Committee to reconsider whether to regulate stone fireplace surrounds and other heavy decorative items requiring substantial fixings.
Verbatim wording from the response “A lot has been done to raise awareness however; given the tragic nature of this incident I will ask the Building Regulations Advisory Committee to re-consider their previous advice not to regulate for stone fire surrounds (and other heavy decorative items that require substantial fixings for their safety, such as large mirrors). Additionally I will make arrangements through authorised schemes, including the Gas Safe Register and HETAS, to alert their registered installers of gas fires and wood burning stoves to good practice guidance on the fixing of stone fireplace surrounds.” Source location 2017-0261-Response-by-Department-for-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 Regulating decorative fireplace surrounds was considered impractical because householders are difficult to regulate and building-regulation awareness is low.
Verbatim wording from the response “The Building Regulations do not control fixtures such as decorative fireplace surrounds. The issue was previously considered by the Building Regulations Advisory Committee, industry experts and technical specialists from my department who looked at options for revising the statutory guidance in relation to compliance with the Building Regulations’ requirements on structures (Approved Document A).” Source location 2017-0261-Response-by-Department-for-Communities-Local-Government
Open published response
Concerns raised 1 Failure to protect the mains-powered alarm system on/off control-switch from unauthorised switching 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
Steven Thomas Billington · 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
Steven Thomas Billington died on 25 March 2015 after inhaling products of combustion from a fire at his home, which began when clothing placed on a maiden in front of a gas fire ignited. The mains-powered fire alarm system had been switched off using an unprotected control switch in an accessible communal area, so it did not warn of the fire. The report raised concern that the switch was not required to be inaccessible to unauthorised people, despite it being simple to protect it, for example in a locked cupboard.
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 protect the mains-powered alarm system on/off control-switch from unauthorised switching
Wider context from the report “The on/off control-switch for the mains powered alarm system was not protected and was therefore able to be switched off. Evidence was given that the relevant regulations do not require the on/off control for such a system to be rendered inaccessible to all but authorised persons.
Further evidence revealed that it would be a simple matter to protect the control by it being placed, for example, in a locked cupboard and this would have no detrimental effect as the control panel for the system that allows it to be reset in the event of false alarm is separately situated from the on/off control-switch.
” Open source report
Concerns raised 1 Lack of automatic water suppression systems in residential 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
Emma Waring · 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
Emma Waring, aged 23, died after a fire in her rented accommodation on 7 March 2015, having been overcome by toxic smoke while attempting to escape. The principal concern was the need to consider compulsory inclusion of domestic automatic water suppression systems, particularly in residential properties housing vulnerable individuals.
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 automatic water suppression systems in residential properties
Wider context from the report “Immediate and positive consideration of the compulsory inclusion in the design, planning and building phases for residential properties (especially for those properties housing vulnerable individuals) of Automatic Water Suppression Systems more commonly known as ‘domestic sprinklers’ so as to provide further safeguards in the event of accidental or indeed deliberate fires in such premises .
” Open source report
Concerns raised 1 Lack of UK regulations requiring child-resistant barriers around private swimming pools View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jack · 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
Jack, a three-year-old boy, was found at the bottom of his family’s unfenced swimming pool after being left in the care of his 20-year-old brother. The substantive concern was that the lack of UK regulations requiring child-resistant barriers around private swimming pools could contribute to future child drownings.
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 UK regulations requiring child-resistant barriers around private swimming pools
Wider context from the report “I received evidence that in Australia and France it is compulsory to fence private swimming pools with child resistant barriers. I am concerned that the lack of regulations in the UK could contribute to future death from children drowning in unfenced swimming pools.
” 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 Owners and occupiers are responsible for identifying and reducing swimming-pool safety hazards on their property.
Verbatim wording from the response “Instead, it is expected that owners/occupiers will be responsible for the safety of people upon their property, identifying hazards and seeking to reduce them by implementing the kind of straightforward measures advised by RoSPA. The Health and Safety Executive (HSE) publication Managing Health and Safety in Swimming Pools (HSG179), which provides guidance for commercial swimming pools, can also be used for domestic swimming pools.” Source location 2015-0154-Response-by-Department-for-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 Building regulations cannot effectively address swimming-pool safety because they cover limited new work, exclude outdoor pools, lack retrospective effect, and are difficult to enforce.
Verbatim wording from the response “We take the view that building regulations would not be the best way to ensure that swimming pools are safe, as they apply only where building work takes place. The definition of a building for the purposes of the regulations does not currently cover an outdoor pool. Furthermore, as the regulations only cover new work, they could not be applied retrospectively to existing pools. Also, any requirement would be very difficult to enforce as it would not be possible to prevent fences from being removed after installation.” Source location 2015-0154-Response-by-Department-for-Communities-and-Local-Government
Open published response
Concerns raised 28 Failure of the youth diversion project to provide diversion before criminal justice processing View source Failure to record and explain incomplete medical assessments View source Failure to return completed Appropriate Adult forms to Social Services View source Interagency confusion about safeguarding roles and access to information View source Failure to initiate youth offending and mental health monitoring after case transfer View source Failure to pass complete incident information to attending officers View source Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs View source Insufficient availability of accommodation for children under 17 View source Insufficient recording of safeguarding information by Appropriate Adults View source Failure of youth offending teams to transfer and oversee cases after relocation View source Failure to assess police information when selecting an Appropriate Adult View source Lack of legally required accommodation for 17-year-olds refused bail View source Failure to make safeguarding referrals from custody medical information View source Failure to record safeguarding intelligence on nominal profiles View source Failure to conduct police database checks on standard-risk DASH referrals View source Failure to route domestic violence cases involving 17-year-old children to child protection review View source Lack of shared understanding between police and MEDACS about requested medical assessments View source Lack of interagency understanding for sharing safeguarding information between police and CPS View source Failure to provide Appropriate Adults with relevant custody risk information View source Failure to provide differentiated mental health assessments for children in custody View source Failure to document information provided to MEDACS before medical assessments View source Failure to check and update Prisoner Escort Records before release View source Custody handovers dependent on officers’ and staff’s unpaid free time View source Lack of consistent child safeguarding coverage across Manchester local authorities View source Lack of clear officer guidance for raising safeguarding concerns View source Unclear referral routes for non-criminal safeguarding concerns View source Lack of a process for recording safeguarding concerns View source Lack of a non-criminal safeguarding policy View source See 25 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
Kesia Lena Mary Leatherbarrow · 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
Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.
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 of the youth diversion project to provide diversion before criminal justice processing
Wider context from the report “The court heard evidence that in Tameside this signposting is only taking place to the mental health services once the young person has been processed through the Criminal Justice System and is not in fact acting as a diversion pathway . There was no evidence from those working in custody that any consideration was given to this scheme for Kesia and there appeared to be little knowledge of the scheme .
” 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 record and explain incomplete medical assessments
Wider context from the report “It was clear that a medical assessment could not be completed and in these circumstances this should be fully explained to the police and the record endorsed accordingly rather than simply endorsing that someone is fit to be detained/interviewed or transferred .
” 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 return completed Appropriate Adult forms to Social Services
Wider context from the report “Evidence from Tameside Social Services indicated that they did not receive the completed form in relation to Kesia and that it was not unusual not to receive the completed forms in any cases.
” 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 Interagency confusion about safeguarding roles and access to information
Wider context from the report “Having heard the evidence the Court felt that there was a degree of confusion and misunderstanding between all the agencies as to their roles , what they are able and not able to do and also where to access important and effective information .
” 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 initiate youth offending and mental health monitoring after case transfer
Wider context from the report “This did not occur as the file had not been processed at the time of Kesia’s death but also because of the confusion between the Youth Offending Teams involved with Kesia which meant she was never picked up by Tameside . The plan that Kesia should be monitored for any interim changes in her risk did not therefore occur .
” 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 pass complete incident information to attending officers
Wider context from the report “The Court heard evidence as to the failure to pass on complete information to the officers who then subsequently attended on Kesia including on one occasion the fact that it had been communicated that she had a knife . The court heard evidence that the failure to pass on important information could impact on the safety of the officers and others and also lead to missed opportunities for safeguarding.
” 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 Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs
Wider context from the report “This was not the system in Manchester and the Court heard evidence that the development of MASHs across Manchester is still ongoing. The Court heard evidence that in Manchester different hubs work differently with different agendas – some relate to domestic violence only and not all of them deal with safeguarding of children .
” 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 availability of accommodation for children under 17
Wider context from the report “The Inquest heard that across Greater Manchester it is estimated that, until recently, in only 10% of cases where the police requested such a service from a local authority a bed was available . Attempts are being made to address this issue but at present the figure remains approximately 20% and the Inquest heard evidence that this was, “not good enough”.
Again the facts heard at this Inquest seem to suggest that children younger than 17 are at risk of being held in custody longer than necessary due to a lack of appropriate facilities . The court heard evidence that the police are in the undesirable position of having to decide whether to detain someone (potentially unlawfully) or release them when they feel it may be unsafe to do so.
” 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 recording of safeguarding information by Appropriate Adults
Wider context from the report “The quality of the information given by the appropriate adult on the completed form was insufficient in light of all the information which had been made available to her about Kesia and the behaviour she had witnessed. Important information such as the threat made by Kesia was not placed onto the form
” 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 youth offending teams to transfer and oversee cases after relocation
Wider context from the report “There was a failure by Lancashire to note her move which led to a delay in her case being transferred, but in addition there was a failure in the communications with Tameside for each team to understand what was being requested and to have oversight of the situation. This led to a lack of involvement with Kesia and a proposal to breach her. It also meant that no effective work was being carried out with her and a missed opportunity to recognise her developing situation in terms of her lack of residence and drug use.
” 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 assess police information when selecting an Appropriate Adult
Wider context from the report “It was not her understanding of the system in place that she should be assessing the information given to her by the police to consider whether it was more suitable for the attendance of a Social Worker.
” 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 legally required accommodation for 17-year-olds refused bail
Wider context from the report “There remains no legal requirement for local authorities to provide accommodation for 17 year olds who will then have to remain in police custody if bail is refused. The result is that 17 year old children risk being kept in custody for longer than necessary if there is nowhere suitable for them to be bailed to.
” 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 make safeguarding referrals from custody medical information
Wider context from the report “Similarly the Court heard that no safeguarding referral was made about Kesia despite information about her self-harming, drug and alcohol use .
” 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 record safeguarding intelligence on nominal profiles
Wider context from the report “No intelligence was placed on Kesia’s nominal profile despite a number of concerning contacts with her by officers . It is a core function of the police to submit such intelligence.
” 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 conduct police database checks on standard-risk DASH referrals
Wider context from the report “when a Domestic Abuse, Stalking and Harassment form (DASH) is submitted to the PPI unit, where the risk level is standard then no checks on the Police National Computer or the Police National Database are carried out . The rationale for this was not clear although DC Evans indicated this may be due to the volume of work. Clearly the PNC can hold vital information about a potential offender .
” 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 route domestic violence cases involving 17-year-old children to child protection review
Wider context from the report “For domestic violence incidents the closing code relates to people over the age of 16 as being adults. This means that the case is not then automatically passed through to the Child Protection Team within Greater Manchester Police for a review even if one of the people involved is still a child - i.e. is 17 years of age.
” 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 shared understanding between police and MEDACS about requested medical assessments
Wider context from the report “It was apparent to the Court that the expectations of the police as to the precise medical assessment being carried out and the conclusions of the assessment may not always be the same as the expectations and understanding of MEDACS .
” 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 interagency understanding for sharing safeguarding information between police and CPS
Wider context from the report “There was a lack of understanding between GMP and the CPS as to how such important information should be shared between agencies .
” 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 provide Appropriate Adults with relevant custody risk information
Wider context from the report “She was not advised that Kesia had been assessed as intoxicated and arrival, nor that she had been seen by MEDACS , nor that she had threatened to jump off a bridge on her release.
” 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 provide differentiated mental health assessments for children in custody
Wider context from the report “The Court also heard evidence that the same medical assessment is carried out for every detained person in custody regardless of whether that is a 17 year old child with mental health difficulties or a 69 year old man with a heart condition. There is no difference in the mental health assessments for children as opposed to adults .
” 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 document information provided to MEDACS before medical assessments
Wider context from the report “there was no clarity as to whether this included previous risk assessments , whether this was a complete record and there was no recorded evidence to indicate what information had been passed to MEDACS by the police and who had provided the information.
” 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 check and update Prisoner Escort Records before release
Wider context from the report “The Prisoner Escort Record form was completed over 12 hours prior to Kesia leaving police custody. It was not checked or amended prior to her release and it failed to contain crucial information indicating that whilst in custody Kesia had made a threat to jump from a bridge.
” 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 Custody handovers dependent on officers’ and staff’s unpaid free time
Wider context from the report “The system at present relies on officers and staff attending work early and sometimes staying late after a 12 hour shift to provide a handover. Whilst it is clear there would need to be some overlap in the times people are on duty, the Court heard evidence as to the quality of the handovers which is clearly impacted by the fact that this crucial part of the information sharing process relies entirely on the free-time of officers and staff .
” 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 consistent child safeguarding coverage across Manchester local authorities
Wider context from the report “This will mean that there is a lack of consistency in approach across the different local authorities in Manchester as to what will be dealt with. Worryingly some will not deal with the safeguarding of children
” 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 officer guidance for raising safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” 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 Unclear referral routes for non-criminal safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” 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 a process for recording safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns . There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” 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 a non-criminal safeguarding policy
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal . There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” Open source report
Concerns raised 6 Unavailability of a shared formal pathway of help for young people who resist engagement View source Failure to hold urgent multi-agency discussions involving all relevant agencies for young people at risk of self-harm View source Insufficient agency capacity to address self-harm appropriately View source Lack of a system encouraging young people to report another young person’s self-harm to those able to help View source Omission of blood pressure checks from annual health checks for looked after children View source Failure of training for professionals working with young people to support recognition and discovery of self-harm View source See 3 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
Aleysha Martine Karla McLoughlin · 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
Aleysha Martine Karla McLoughlin, aged 16, died by hanging at her foster home on 3 April 2014 after a history of self-harm, overdoses and assessed ongoing risk of impulsive self-harm. The concerns included training for professionals to recognise self-harm, systems for sharing information when young people self-harm, urgent multi-agency discussions including mental health services, and a formal support pathway for young people who resist engagement.
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 Unavailability of a shared formal pathway of help for young people who resist engagement
Wider context from the report “(4) That it should be considered that a particular pathway of help for young people who resist engagement should be developed. There was no evidence that any such formal pathway had been shared at the present time .
” 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 hold urgent multi-agency discussions involving all relevant agencies for young people at risk of self-harm
Wider context from the report “(3) That it should be considered that systems such as those now being developed in Bolton should be further developed so as to ensure that multi agency discussions involving all relevant agencies are held urgently for those at risk of self harm and particularly for those who do not engage . Evidence was given that meetings concerning Aleysha Martine Karla McLoughlin did not include the Child and Adolescent Mental Health Services although evidence was given that their input would have been valuable.
” 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 agency capacity to address self-harm appropriately
Wider context from the report “(5) That a review of the capacity of the agencies involved in helping young people who are self harming to address those matters appropriately should be considered.
” 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 a system encouraging young people to report another young person’s self-harm to those able to help
Wider context from the report “(2) That it should be considered that additional information and encouragement could be offered to young people to inform those able to help for example teachers, nurses, health professionals etc. when a young person becomes aware that another young person is self harming. The shocking self harm to which Aleysha Martine Karla McLoughlin had subjected herself was only revealed when a school friend brought it to the attention of a teacher. There was no evidence that there was any system in place to encourage the passing of such information .
” 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 Omission of blood pressure checks from annual health checks for looked after children
Wider context from the report “(1) That it should be considered that the system of training for those working with young people, including teachers, school nurses, foster carers, social workers, mental health workers and medical nurses and doctors should be reviewed so as to ensure that these professionals should be alert for signs of self harm and should take opportunities to discover themselves so that those harming themselves can be offered help and support. By way of example evidence was given at the Inquest that the annual health check offered to looked after children did not include a blood pressure check . If a blood pressure check was included this would provide an opportunity for signs of self harm to be revealed .
” 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 training for professionals working with young people to support recognition and discovery of self-harm
Wider context from the report “(1) That it should be considered that the system of training for those working with young people, including teachers, school nurses, foster carers, social workers, mental health workers and medical nurses and doctors should be reviewed so as to ensure that these professionals should be alert for signs of self harm and should take opportunities to discover themselves so that those harming themselves can be offered help and support. By way of example evidence was given at the Inquest that the annual health check offered to looked after children did not include a blood pressure check. If a blood pressure check was included this would provide an opportunity for signs of self harm to be revealed.
” Open source report
Concerns raised 10 Insufficient capacitor safety requirements to prevent hazards on failure View source Lack of requirements to isolate or protect refrigeration-appliance insulation from ignition View source Failure to identify appliance fire causes and appliance identifiers after fire damage View source Lack of second-hand market controls for recalled or safety-notice products View source Failure to routinely pass identified domestic appliance fire information to Trading Standards or manufacturers View source Underestimation of capacitor-related fire risk in Beko fridge-freezer risk assessment View source Inconsistent guidance on product risk notification and corrective action View source Lack of awareness of the safety notice for recalled Beko fridge-freezer models View source Inconsistent product safety risk assessments omitting or variably weighting serious injury factors View source Lack of requirements for less flammable or better-contained plastic materials in refrigeration appliances View source See 7 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
Santosh Benjamin Muthiah · 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
Santosh Benjamin Muthiah died after a fire spread through his home while he and his family were sleeping, with the medical cause recorded as cerebral anoxia due to inhalation of fire fumes. The report raised concerns about the identification and communication of appliance-fire information, risks from recalled and second-hand refrigeration appliances, product safety risk assessments, guidance and notification practices, and the construction and components of refrigeration appliances, including capacitors.
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 capacitor safety requirements to prevent hazards on failure
Wider context from the report “24. I heard evidence for the LFB witnesses, in particular ████████, who gave evidence about the serious concerns they hold about the ongoing risk posed by capacitor failures resulting in fires. These concerns are twofold, relating generally to capacitors and the industry standards and in relation to Beko appliances.
25. Paragraph 24.8 of British Standard BS EN 60335-1:2012 ‘Household and similar electrical appliances; Safety; Part 1 - General requirements.’ applies to the type of capacitors used in refrigeration appliances. It states that they shall not cause a hazard in the event of failure.
26. This requirement is considered to be met by one or more of the following conditions:
a. The capacitors are of a class of safety protection P2 according to IEC 60252-1;
b. The capacitor is housed within a metallic or ceramic enclosure that will prevent the emission of flame or molten material resulting from failure of the capacitor;
c. The distance of separation of the outer surface of the capacitor to adjacent non-metallic parts exceeds 50mm;
d. Adjacent non-metallic parts within 50 mm of the outer surface of the capacitor withstand the needle-flame test of Annex E;
e. Adjacent non-metallic parts within 50 mm of the outer surface of the capacitor are classified as at least V-1 according to IEC 60695-11-10, provided that the test sample used for the classification was no thicker than the relevant part of the appliance.
27. I accept and agree with the concern raised by the LFB that the above requirement does not ensure that capacitors do not pose a hazard . This creates a risk to the safety of consumers.
28. The LFB FIT has experience of failures of P2 capacitors and failures leading to ignition of metal casing capacitors (contrary to a. and b. above).
29. Further, it is clear that the mechanisms of failure of a capacitor can bypass the required 50mm distance (contrary to c. above). Furthermore, in the case of a refrigeration appliance, the base of the compressor compartment is often two metal bars used for mounting components, leaving the floor surface exposed (for example a flammable carpet).
30. The LFB believes that the requirements regarding capacitors referred to in paragraph 50 above (citing paragraph 24.8 British Standard BS EN 60335-1 : 2012) are not robust enough to prevent capacitors from presenting a hazard , which creates a risk to the safety of consumers.
” 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 requirements to isolate or protect refrigeration-appliance insulation from ignition
Wider context from the report “20. I heard evidence from the LFB witnesses who gave evidence concerning the inherent risks that refrigeration appliances present due to their construction. The polyurethane insulation material used in most refrigeration appliances represents a high fuel load, is highly flammable and when on fire burns to create dangerous gases.
21. There is no legal requirement or industry standard that this insulation material is isolated from or protected from ignition by a failure in another component within the appliance , which represent a risk of ignition, such as the compressor, capacitor or ancillary components. This represents a serious risk to the safety of consumers .
” 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 identify appliance fire causes and appliance identifiers after fire damage
Wider context from the report “1. I heard evidence from various witnesses, including the LFB but also from Beko and ████████ formerly of Intertek, that there are often problems in identifying, not just the specific cause of an appliance fire, but even the manufacturer, model and serial number of the appliance in question due to the severity of the fire damage . This has a knock on effect on Fire & Rescue Services’ (“FRS’s”), Trading Standards (“TS”) and manufacturers’ ability to accurately identify a pattern or trend within fires from appliances which may evidence a specific manufacturing or component problem.
2. This creates a risk that the nature and extent of a potential problem with a particular manufacturer or particular appliance is not fully known and therefore underestimated with the consequence that the risk to the lives of consumers may also be underestimated.
” 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 second-hand market controls for recalled or safety-notice products
Wider context from the report “8. I heard evidence from the LFB witnesses who gave some evidence that defective products on the second hand market pose a continuing risk to consumers.
9. There is no clear system in place to ensure that products subject to a safety notice or recall are not sold, unmodified, on the second hand market . By way of example, the LFB has recently identified several unmodified Beko fridge freezers which are subject to the safety notice, for sale in a second hand retailer. This lack of regulation or market surveillance of the second hand market poses a risk to consumers .
” 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 routinely pass identified domestic appliance fire information to Trading Standards or manufacturers
Wider context from the report “6. This is not the case routinely elsewhere in the country. There may be a variety of reasons for this, including the difficulty in identifying the appliances due to fire damage, and the more limited resources and expertise in the investigation of the causes of fires that other FRS’s have in contrast to the fortunate position of the LFB.
7. Whatever the reasons there is a risk in existence where such information that is gathered by FRS’s in relation to fires involving domestic electrical appliances (where the appliance can be identified) is not routinely passed to the appropriate TS Home or Primary Authority or indeed to the manufacturer . TS is taking decisions on whether to take any action in relation to a particular manufacturer or a particular appliance on less than all the available information. If they were provided with more accurate information about the incidences of appliance fires they would be in a better position to take action where necessary.
” 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 Underestimation of capacitor-related fire risk in Beko fridge-freezer risk assessment
Wider context from the report “31. I heard evidence from LFB witnesses who gave evidence of their concerns that serious failures in Beko Frost Free Fridge Freezers (“FFFF’s”) manufactured between 2000 and 2006 are continuing resulting in a serious risk to the safety of consumers. ████████ gave evidence of the numbers of fires which the LFB FIT have investigated to date, the appliance models and the causes of the fires. The LFB have written to Beko concerning these fires and the risk the appliances represent. This concern relates in large part to capacitor failures.
32. Although it is right to say that there was some evidence that there may be an “industry wide problem” i.e. that this risk is not specific to Beko, this alone does not address the risk which exists in Beko products and nor have the LFB been concerned enough in relation to the risk presented by other manufacturer’s products to write to any of them.
33. The LFB were provided with a risk assessment from Beko dated 26 April 2012 which states that the risk is “low” such that no action is necessary or proposed. The LFB is concerned that this underestimates the risk to the safety of consumers , particularly as Beko witnesses’ own evidence seemed to highlight that they consider the capacitor as a potential ignition source in fires .
” 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 Inconsistent guidance on product risk notification and corrective action
Wider context from the report “16. I heard from Beko witnesses and also, in particular, ████████ that there are inconsistencies between the EU Commission Guidance and the UK Trade Association Guidance on corrective action and the requirement to notify an enforcement authority .
17. The AMDEA guidance says that if the outcome of the risk assessment is that there is a “moderate” risk, the manufacturer is not required to notify TS but the BIS guidance says that a “moderate” risk outcome requires notification to TS.
18. Manufacturers therefore are in difficulty in consistently applying guidance and in carrying out their notification obligations where there is the requisite level of risk to consumers.
19. I accept the LFB submissions that such inconsistency creates a risk that TS not being notified and therefore action not being taken in circumstances when it arguably should be highlighting a risk to consumers.
” 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 awareness of the safety notice for recalled Beko fridge-freezer models
Wider context from the report “10. I heard evidence from the LFB witnesses of their concerns that serious failures in Beko Frost Free Fridge Freezers (“FFFF’s”) manufactured between 2000 and 2006 are continuing resulting in a serious risk to the safety of consumers. ████████ gave evidence of the numbers of fires which the LFB FIT have investigated to date, the appliance models and the causes of the fires.
11. The LFB submits that there remains a risk in relation to the lack of or minimal awareness of the current safety notice in relation to these Beko models .
” 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 Inconsistent product safety risk assessments omitting or variably weighting serious injury factors
Wider context from the report “12. I heard a great deal of evidence concerning the process of risk assessment and the factors to be taken into account when considering the potential seriousness of injury and the likelihood of a risk eventuating.
13. It is the view of the LFB that the following matters should always be taken in to account when carrying out a product safety risk assessment:
a. Sleeping risk – i.e. the fact that a person is more vulnerable to the risks of fire when asleep;
b. The most serious consequence of a product failure i.e. in the case of fire, serious injury or death;
c. The potential long term physical impact on persons who have suffered burns injuries;
d. The possible psychological impact on persons who have suffered the trauma of a fire.
14. It was clear from the evidence that there have been and continue to be different approaches to risk assessment adopted . The evidence from ████████ and the evidence from the face of the Arcelik and Intertek Risk Assessments (in documentary form) made at the material times over a period of a number of years show that some of these factors are not taken into account and some may be taken into account to a variable degree .
15. Failing to take these factors into account expressly creates a risk that the seriousness of injury, and consequently, potentially the seriousness of the overall risk is underestimated .
” 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 requirements for less flammable or better-contained plastic materials in refrigeration appliances
Wider context from the report “23. The plastic materials which are used for filling, strengthening and insulating refrigeration appliances are highly flammable and increase the fuel load of these appliances posing a continuing risk to consumers . It is possible to use alternate, non-flammable or less flammable materials. It is also possible to better contain such combustible components or insulation. There is no such requirement at present which creates a risk to the safety of consumers .
” Open source report
Concerns raised 3 Failure to replace safety-noncompliant glass except during refurbishment or after breakage View source Presence of safety-noncompliant glass in older rented housing stock View source Lack of a legal requirement for landlords or letting agents to assess glass safety View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Wade Dayabhai Patel · 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
Wade Dayabhai Patel was found in the hallway of his home after falling through an inner glass door, sustaining leg injuries that led to his death. The report raised concerns that the property’s original glass did not comply with current safety requirements and that there was no legal requirement for landlords or letting agents to specifically assess glass 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 replace safety-noncompliant glass except during refurbishment or after breakage
Wider context from the report “My understanding is that there is no legal requirement for a landlord or letting agent, to look specifically at safety of glass in a property. I further understand, for example, that there is recent legislation that enhances gas safety, requiring regular checking and recording of the checks by a suitably qualified person.
It therefore seems that such glass will only be replaced either in the process of a refurbishment of the property (thereby complying with current building regulations), or when the glass breaks and requires replacement .
” 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 Presence of safety-noncompliant glass in older rented housing stock
Wider context from the report “The glass in the door is likely to have been the original glass, the property having been built in the 1930's. For obvious reasons the glass did not comply, from a safety viewpoint, with current legislation including building regulations.
Much of our housing stock will be of similar age, or older than, ████████ A significant proportion of that stock will be rented.
” 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 a legal requirement for landlords or letting agents to assess glass safety
Wider context from the report “My understanding is that there is no legal requirement for a landlord or letting agent, to look specifically at safety of glass in a property . I further understand, for example, that there is recent legislation that enhances gas safety, requiring regular checking and recording of the checks by a suitably qualified person.
It therefore seems that such glass will only be replaced either in the process of a refurbishment of the property (thereby complying with current building regulations), or when the glass breaks and requires replacement.
” Open source report
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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 Government has no plans to require existing doors to meet current Building Regulations, given their non-retrospective application and major implications for existing buildings.
Verbatim wording from the response “However, the Building Regulations only apply where building work takes place, typically the erection or extension of a building and the Building Act 1984 does not provide for the retrospective application of current standards to existing buildings. The Regulations therefore will not require that existing doors be made to comply with current standards unless building work subject to the Regulations is carried out to the part of the building in question. Requiring old buildings, designed and built with very different standards in mind, to meet the most modern Building Regulation requirements would have major implications for” Source location 2014-0434-Response-by-Department-for-Communities-Local-Government
Open published response
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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 Government has no plans to change the HHSRS because its guidance already identifies collisions with doors as a hazard.
Verbatim wording from the response “The quality of privately rented housing has improved rapidly over the past decade, and levels of satisfaction compare well to other tenures. However, a small minority of properties in the sector are in poor condition. Tenants have a right to live in safe and well maintained homes and local authorities have strong powers to tackle poor quality accommodation in their area. We expect them to use those powers if necessary. Where a serious hazard is identified, the local authority must take appropriate action. This can include formal action such as issuing an improvement notice requiring the owner to make improvements to the property, banning the use of the whole or part of a dwelling or taking emergency action to fix the hazard where there is an immediate risk to health and safety.” Source location 2014-0434-Response-by-Department-for-Communities-Local-Government
Open published response
Concerns raised 2 Lack of guidance requiring planning authorities to consider tall-building wind effects on highway users View source Lack of appropriate criteria for assessing tall-building wind effects on highway-user safety 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.
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AI-generated summary
Dr Edward James Slaney · 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
Dr Edward James Slaney was crossing a road in Leeds when a medium-sized goods vehicle was blown over by high wind gusts near Bridgewater Place, trapping him underneath and causing fatal chest injuries. The principal concerns were the lack of criteria for assessing the safety effects of tall-building wind conditions on all highway users and the lack of planning guidance on those effects.
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 guidance requiring planning authorities to consider tall-building wind effects on highway users
Wider context from the report “(2)Guidance should be provided to all planning authorities that consideration should be given to the wind effects of tall buildings upon all highway users namely high-sided vehicles, motor cars, motor bikes, pedal cycles and pedestrians
” 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 appropriate criteria for assessing tall-building wind effects on highway-user safety
Wider context from the report “(1)When considering the wind effect which is likely to be created by the construction of a tall building, appropriate criteria should be established in relation to the safety of all highway users ;
” Open source report
Concerns raised 14 Unavailability of carbon monoxide detection equipment on Fire and Rescue Service frontline appliances View source Absence of a statutory Fire and Rescue Service role in carbon monoxide safety, regulation and enforcement View source Lack of suitable training in the operation of carbon monoxide detection equipment View source Lack of clear oversight of gas-supplier steps to raise awareness of danger View source Lack of clear gas-supplier criteria for identifying vulnerable and priority customers View source Failure to identify incomplete flue piping during routine inspections View source Lack of understanding and detailed guidance on the movement of carbon monoxide within buildings View source Lack of established monitoring of offers and uptake of free annual gas safety checks View source Lack of a duty to warn other occupants to install carbon monoxide alarms View source Lack of regulatory coverage for ongoing maintenance and inspection of existing solid fuel appliances View source Lack of a duty to allow recognised engineers to inspect boilers in multi-occupancy buildings View source Lack of required audit trails of fuel-supplier carbon monoxide safety steps View source Lack of HSE guidance to landlords and letting agents on independent validation of gas and other fuel safety equipment in rented property View source Lack of required specific carbon monoxide safety information from fuel suppliers View source See 11 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
ELIZABETH AURORA KERR · 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
Elizabeth Aurora Kerr died after carbon monoxide from a malfunctioning basement boiler entered the residential flat where she lived, and she was found unconscious several hours after the Fire Service had attended the building. The report identified concerns about the movement and detection of carbon monoxide in buildings, the absence and use of carbon monoxide alarms and gas safety controls, and Fire and Rescue Service equipment, guidance and responses.
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 Unavailability of carbon monoxide detection equipment on Fire and Rescue Service frontline appliances
Wider context from the report “7. The use and availability of CGI meters by Fire and Rescue Services and having suitable training in their operation as well as the use of personal protective equipment CO alarms.
GMFRS did some research in the use of such equipment by all Fire and Rescue Services. Please see the attached. It is suggested that if all Fire and Rescue Services carried such equipment on front line appliances and used them on both emergency responses and preventative work that would reduce the risk of death to Fire Fighters and the public.
” 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 Absence of a statutory Fire and Rescue Service role in carbon monoxide safety, regulation and enforcement
Wider context from the report “3. The Role of Fire and Rescue Services in Carbon Monoxide Safety:
The Fire and Rescue Services currently have no statutory role in Carbon Monoxide safety, regulation and enforcement. This could be reviewed and considered by the Department for Communities and Local Government. It is appreciated that this is far from straight forward and wider issues would need to be taken into account. For example Fire and Rescue Services have no statutory role in other gases or substances which can cause death. This may require a more detailed analysis and assessment of issues and complications which may then come to light. In the absence of a statutory role, and possibly through the Chief Fire Officers Association “Blue Watch” initiative, Fire and Rescue Services could be encouraged to voluntarily engage in local and national Carbon Monoxide campaigns. Such campaigns may benefit from closer working at a local level with relevant CO charities and at a national level between the Gas Safety Trust, the Gas Safe Charity and the Chief Fire Officers Association.
” 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 suitable training in the operation of carbon monoxide detection equipment
Wider context from the report “7. The use and availability of CGI meters by Fire and Rescue Services and having suitable training in their operation as well as the use of personal protective equipment CO alarms.
GMFRS did some research in the use of such equipment by all Fire and Rescue Services. Please see the attached. It is suggested that if all Fire and Rescue Services carried such equipment on front line appliances and used them on both emergency responses and preventative work that would reduce the risk of death to Fire Fighters and the public.
” 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 oversight of gas-supplier steps to raise awareness of danger
Wider context from the report “4. Piped Gas Suppliers:
It is understood that there are specific conditions of a licence to supply gas as summarised below. It is not clear how gas suppliers define and determine who is a ”vulnerable and priority” customer and how it is established that they have been offered a free annual gas safety check, and have taken advantage (or not) of such an offer ? Nor who actually checks what steps a gas supplier takes in practice to raise the awareness of danger and who judges the reasonability of the steps?
” 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 gas-supplier criteria for identifying vulnerable and priority customers
Wider context from the report “4. Piped Gas Suppliers:
It is understood that there are specific conditions of a licence to supply gas as summarised below. It is not clear how gas suppliers define and determine who is a ”vulnerable and priority” customer and how it is established that they have been offered a free annual gas safety check, and have taken advantage (or not) of such an offer ? Nor who actually checks what steps a gas supplier takes in practice to raise the awareness of danger and who judges the reasonability of the steps?
” 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 identify incomplete flue piping during routine inspections
Wider context from the report “8. The Chief Fire Officers Association “Blue Watch Initiative”
This is a voluntary initiative to be encouraged and supported. It offers an independent safety validation service for landlords and letting agents.
http://www.bluewatch.co.uk/. The investigation established that incomplete flue piping had not been identified on routine inspection visits despite the regulatory regime created by The Gas Safety (Installation and Use ) Regulations 1988. At present there is no duty imposed on the owner of a boiler or a gas supplier ( who makes a profit from the supply ) that in the case of a multi occupancy building to allow the other occupants , through recognised engineers , to inspect the boiler and be warned to install CO alarms.
” 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 understanding and detailed guidance on the movement of carbon monoxide within buildings
Wider context from the report “2. Guidance on the potential movement of CO within a building:
There appears to be a lack of understanding and detailed guidance on the potential movement of CO within a building from its original source and how it can penetrate and move within it. The HSE could provide more information on its web site and provide specific guidance or warnings. There is no HSE guidance to landlords and letting agents as to what independent validation has taken place of the gas and other fuel safety equipment provided in rented property may be appropriate. Such information could also be disseminated to and within all Fire and Rescue Services.
” 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 established monitoring of offers and uptake of free annual gas safety checks
Wider context from the report “4. Piped Gas Suppliers:
It is understood that there are specific conditions of a licence to supply gas as summarised below. It is not clear how gas suppliers define and determine who is a ”vulnerable and priority” customer and how it is established that they have been offered a free annual gas safety check, and have taken advantage (or not) of such an offer ? Nor who actually checks what steps a gas supplier takes in practice to raise the awareness of danger and who judges the reasonability of the steps?
” 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 a duty to warn other occupants to install carbon monoxide alarms
Wider context from the report “8. The Chief Fire Officers Association “Blue Watch Initiative”
This is a voluntary initiative to be encouraged and supported. It offers an independent safety validation service for landlords and letting agents.
http://www.bluewatch.co.uk/. The investigation established that incomplete flue piping had not been identified on routine inspection visits despite the regulatory regime created by The Gas Safety (Installation and Use ) Regulations 1988. At present there is no duty imposed on the owner of a boiler or a gas supplier ( who makes a profit from the supply ) that in the case of a multi occupancy building to allow the other occupants , through recognised engineers , to inspect the boiler and be warned to install CO alarms.
” 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 regulatory coverage for ongoing maintenance and inspection of existing solid fuel appliances
Wider context from the report “6. The installation , use , maintenance and correct positioning of fixed hard wired or battery operated CO alarms.
From October 1st 2010 Building Regulations Approved Document J “Combustion appliances and fuel storage systems” sets out a number of legal requirements in England and Wales. For the first time carbon monoxide (CO) alarms were made mandatory “where a new or replacement fixed solid fuel appliance is installed in a dwelling, a CO alarm should be provided in the room where the appliance is located.” However Building Regulations only concern the processes used during the ‘building’ or ‘installation’ phases, of a solid fuel appliance and do not have any power to talk about on-going maintenance processes or the inspection of existing appliances.
” 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 a duty to allow recognised engineers to inspect boilers in multi-occupancy buildings
Wider context from the report “8. The Chief Fire Officers Association “Blue Watch Initiative”
This is a voluntary initiative to be encouraged and supported. It offers an independent safety validation service for landlords and letting agents.
http://www.bluewatch.co.uk/. The investigation established that incomplete flue piping had not been identified on routine inspection visits despite the regulatory regime created by The Gas Safety (Installation and Use ) Regulations 1988. At present there is no duty imposed on the owner of a boiler or a gas supplier ( who makes a profit from the supply ) that in the case of a multi occupancy building to allow the other occupants , through recognised engineers , to inspect the boiler and be warned to install CO alarms.
” 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 audit trails of fuel-supplier carbon monoxide safety steps
Wider context from the report “5. Enforcement and Information:
There is no requirement that in the case of a carbon monoxide death, a clear audit trail is available of the steps taken by the relevant fuel supplier to ensure the specific customer in question was aware of the dangers of carbon monoxide poisoning and the benefits of fitting an audible alarm. At the moment there is no specific information that fuel suppliers are required to give.
” 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 HSE guidance to landlords and letting agents on independent validation of gas and other fuel safety equipment in rented property
Wider context from the report “2. Guidance on the potential movement of CO within a building:
There appears to be a lack of understanding and detailed guidance on the potential movement of CO within a building from its original source and how it can penetrate and move within it. The HSE could provide more information on its web site and provide specific guidance or warnings. There is no HSE guidance to landlords and letting agents as to what independent validation has taken place of the gas and other fuel safety equipment provided in rented property may be appropriate. Such information could also be disseminated to and within all Fire and Rescue Services.
” 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 specific carbon monoxide safety information from fuel suppliers
Wider context from the report “5. Enforcement and Information:
There is no requirement that in the case of a carbon monoxide death, a clear audit trail is available of the steps taken by the relevant fuel supplier to ensure the specific customer in question was aware of the dangers of carbon monoxide poisoning and the benefits of fitting an audible alarm. At the moment there is no specific information that fuel suppliers are required to give.
” Open source report
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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