19 Apr 2026 Paul HUTCHINSON · Prevention of Future Deaths report West London
View report summary
Concerns raised 5 Failure to standardise staff training on evacuation, alarm, telecare and fire suppression procedures View source Failure of Fire Risk Assessments to account for vulnerable residents at special risk View source Lack of timescales for regular reviews of PCFRAs and personal emergency evacuation arrangements View source Lack of specific requirements for PCFRAs and personal emergency evacuation plans with agreed formats and risk factors View source Lack of specific requirements for emergency equipment and staff training View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Paul HUTCHINSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul HUTCHINSON died of burns after setting himself alight while smoking in his Extra Care Sheltered Accommodation on 21 January 2025. The report raised concerns about the lack of specific requirements for individual fire risk and evacuation assessments, non-standardised staff training, and whether fire risk assessments adequately considered vulnerable residents who may be unable to self-evacuate.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Failure to standardise staff training on evacuation, alarm, telecare and fire suppression procedures
Wider context from the report “2. Staff training is not standardised for ECSA (or sheltered accommodation more generally) and may not include, for example, evacuation strategy, emergency evacuation plans, the use of telecare/fire alarm system and fire suppression systems .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Failure of Fire Risk Assessments to account for vulnerable residents at special risk
Wider context from the report “3. Fire Risk Assessments for premises providing ECSA and sheltered accommodation more generally may not contemplate vulnerable residents as forming 'any group of persons identified...as being especially at risk' (see article 9(7)(b) of the 2005 Regulations). Vulnerable residents may be at special risk because of (for example) smoking or cooking practices and may have a compromised ability to self-evacuate. The concern is that Fire Risk Assessments do not take this into account .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Lack of timescales for regular reviews of PCFRAs and personal emergency evacuation arrangements
Wider context from the report “1. The Regulatory Reform (Fire Safety) Order 2005 and the Fire Safety (Residential Evacuation Plans) Regulations 2025 do not appear to apply to the individual flats in ECSA because they are private dwellings. The concern is that there is no specific requirement for a PCFRA (or a personal emergency evacuation through the PCFRA) with an agreed format and risk factors, a requirement for emergency equipment and staff training and a timescale for regular reviews (including where the individual circumstances of a person in care change) . This concern may apply to others in formal residential care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Lack of specific requirements for PCFRAs and personal emergency evacuation plans with agreed formats and risk factors
Wider context from the report “1. The Regulatory Reform (Fire Safety) Order 2005 and the Fire Safety (Residential Evacuation Plans) Regulations 2025 do not appear to apply to the individual flats in ECSA because they are private dwellings. The concern is that there is no specific requirement for a PCFRA (or a personal emergency evacuation through the PCFRA) with an agreed format and risk factors , a requirement for emergency equipment and staff training and a timescale for regular reviews (including where the individual circumstances of a person in care change). This concern may apply to others in formal residential care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Lack of specific requirements for emergency equipment and staff training
Wider context from the report “1. The Regulatory Reform (Fire Safety) Order 2005 and the Fire Safety (Residential Evacuation Plans) Regulations 2025 do not appear to apply to the individual flats in ECSA because they are private dwellings. The concern is that there is no specific requirement for a PCFRA (or a personal emergency evacuation through the PCFRA) with an agreed format and risk factors, a requirement for emergency equipment and staff training and a timescale for regular reviews (including where the individual circumstances of a person in care change). This concern may apply to others in formal residential care.
” Open source report
Concerns raised 4 Discrepancies in reporting deaths involving emollient creams to the regulatory authority View source Heightened emollient cream fire risk when elderly or lower-income people use alternative methods to heat their homes View source Lack of effective communication about the dangers of emollient creams near flames or heat View source Lack of awareness among professionals and the public of the extent of emollient cream fire risk View source See 1 more concern
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
James William Rownsley · 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 William Rownsley died at home on 20 February 2025 after his clothing caught fire when he was sitting close to a gas fire. Emollient cream on his clothing was identified as a significant factor, contributing to the intensity and rapid development of the fire. The principal concerns were inadequate awareness and communication among professionals and the public about the ignition risks of emollient creams, and weaknesses in reporting deaths involving such creams.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Discrepancies in reporting deaths involving emollient creams to the regulatory authority
Wider context from the report “3. I was also told that since 2020 there have been 50 deaths in England involving emollient creams but there was a significant discrepancy between the data held by fire services in terms of there being 50 deaths, and the data held by Medicines and Healthcare Products Regulatory agency only had a record of 15. Accordingly, the current system of reporting such data to this regulatory authority should be reviewed with consideration to making this more robust or if there is an absence of such a referral process, for one to be introduced and communicating any such reporting requirements to all fire 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Heightened emollient cream fire risk when elderly or lower-income people use alternative methods to heat their homes
Wider context from the report “5. The risk seems to be heightened in situations where elderly persons or persons of lower income are using such methods to heat their homes to avoid the cost of putting central heating on of the entire property.
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Lack of effective communication about the dangers of emollient creams near flames or heat
Wider context from the report “1. The need for effective communication to partners and stakeholders responsible for either prescribing such emollients, or indeed caring for people in the community, of the dangers of using such creams particularly when in close proximity to flames or heat.
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among professionals and the public of the extent of emollient cream fire risk
Wider context from the report “2. An apparent lack of awareness of the both professionals and the public regarding the extent of that risk.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue national guidance supporting consistent reporting of emollient-related incidents.
Verbatim wording from the response “To further strengthen awareness and reporting, NFCC proposes:” Source location Response from National Fire Chiefs Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver and enhance national emollient fire-risk awareness campaigns, including new training materials for carers and support workers.
Verbatim wording from the response “In 2020, NFCC partnered with MHRA to launch the joint national campaign 'Know the Fire Risk', supported by a multi-agency stakeholder group including fire services, clinicians, and academics. This campaign remains active and has recently been enhanced with new training materials, including a video titled 'Reducing Risk: Information for Carers and Support Workers'. In 2025, the Care Quality Commission (CQC) and the Homecare Association issued updated guidance to health and care providers on the safe use of emollients. NFCC has also embedded emollient-related fire risk into the Person-Centred Home Fire Safety Framework, which underpins prevention activity across all UK fire and rescue services.” Source location Response from National Fire Chiefs Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the response with the host fire and rescue service and Care Quality Commission to reinforce key learning.
Verbatim wording from the response “The NFCC remains committed to supporting fire and rescue services in their prevention efforts and to working collaboratively with health and care partners to reduce the risk of future deaths. We will be sharing our response with the host fire and rescue service and the Care Quality Commission to reinforce the key learning and highlight the work undertaken to date. We would also welcome any support the Coroner may be able to provide in helping to disseminate these important messages across health and adult social care settings, where wider engagement will be essential to preventing similar incidents in the future.” Source location Response from National Fire Chiefs Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed emollient fire-risk assessment and messaging within the Person-Centred Home Fire Safety Framework and Home Fire Safety Visits.
Verbatim wording from the response “In 2020, NFCC partnered with MHRA to launch the joint national campaign 'Know the Fire Risk', supported by a multi-agency stakeholder group including fire services, clinicians, and academics. This campaign remains active and has recently been enhanced with new training materials, including a video titled 'Reducing Risk: Information for Carers and Support Workers'. In 2025, the Care Quality Commission (CQC) and the Homecare Association issued updated guidance to health and care providers on the safe use of emollients. NFCC has also embedded emollient-related fire risk into the Person-Centred Home Fire Safety Framework, which underpins prevention activity across all UK fire and rescue services.” Source location Response from National Fire Chiefs Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore opportunities with fire services and De Montfort University to develop national or regional emollient fire-risk webinars.
Verbatim wording from the response “While awareness has improved, we recognise that further efforts are needed. NFCC is exploring opportunities to support fire and rescue services and De Montfort University in developing national or regional webinars. These would target a broad audience including pharmacists, pharmacy teams, health service prevention teams, GPs, community safety teams, and fire and rescue professionals, building on recent examples such as the Norfolk adult safeguarding intervention.” Source location Response from National Fire Chiefs Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Convene a data review group with MHRA and selected fire and rescue services by December 2025.
Verbatim wording from the response “To further strengthen awareness and reporting, NFCC proposes:” Source location Response from National Fire Chiefs Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage health, care and fire-sector partners and disseminate emollient safety information to strengthen professional awareness.
Verbatim wording from the response “• Continued engagement with MHRA, NHS, CQC, and the Homecare Association.” Source location Response from National Fire Chiefs Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Highlight emollient fire risk during winter preparedness campaigns for 2025/26.
Verbatim wording from the response “We continue to recognise the heightened risk in vulnerable households, particularly among elderly residents, low-income families, and those using alternative heating methods. NFCC has embedded emollient fire risk into the Person-Centred Home Fire Safety Framework, and we will ensure this risk is highlighted during winter preparedness campaigns for 2025/26.” Source location Response from National Fire Chiefs Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and distribute emollient fire-risk campaign toolkits to fire services, NHS partners and care providers.
Verbatim wording from the response “• Developed and distributed campaign toolkits for fire services, NHS partners, and care providers.” Source location Response from National Fire Chiefs Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support rollout of FaRDaP with dedicated emollient-related incident fields by September 2026.
Verbatim wording from the response “• Supporting the rollout of the Fire and Rescue Data Platform (FaRDaP) with emollient-specific fields by September 2026.” Source location Response from National Fire Chiefs Council
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 Access to FaRDaP data is constrained because MHCLG has not agreed formal data sharing and disclosures may be delayed.
Verbatim wording from the response “We are currently engaging with the Ministry of Housing, Communities and Local Government (MHCLG) regarding access to data submitted through FaRDaP. While no formal agreement has yet been reached, our objective is to secure timely and relevant data to support sector-wide analysis. At present, MHCLG has indicated that data sharing will be considered on a case-by-case basis, and any data provided may be subject to delays due to processing and publication timelines.” Source location Response from National Fire Chiefs Council
Open published response
30 Jan 2025 Liam Stephen Allan · Prevention of Future Deaths report West London
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Concerns raised 2 Delays in police alerting of the LFB and subsequent emergency response View source Inadequate visibility of riverside buoyancy aids 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
Liam Stephen Allan · 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
Liam Stephen Allan was arrested alongside the River Thames on the evening of 26 August 2022, entered the river, and drowned. The report identified concerns about inadequate lighting and visibility of riverside buoyancy aids, and about delays in alerting the London Fire Brigade because notification was made by telephone rather than through the faster CAD-mediated system.
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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Delays in police alerting of the LFB and subsequent emergency response
Wider context from the report “The process for alerting the LFB by the Metropolitan Police Service (MPS) uses a telephone to transmit information from the MPS to the LFB , rather than using a CAD-mediated system to transfer information electronically from the Police to the LFB which is faster than transmitting information by telephone . This delay means that there is a risk that future deaths could occur due to a delay in the LFB being alerted by the Police and a corresponding delay to the LFB's subsequent response to an emergency incident .
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate visibility of riverside buoyancy aids
Wider context from the report “The lighting of buoyancy aids on the riverside is not adequate , meaning that they are not able to be identified rapidly and then deployed without delay in an emergency situation.
Buoyancy aids are more visible when painted with white stripes and/or reflective white stripes. However, not all buoyancy aids are so painted , meaning that they are not able to be identified rapidly and then deployed without delay in an emergency situation.
” 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 Configuration of electronic communication systems will be agreed locally by fire and rescue services with relevant partner agencies.
Verbatim wording from the response “the consideration of configuring mobilising systems to integrate with electronic methods of communication. This will take a variety of forms within fire and rescue services and be agreed locally with their relevant partners.” Source location Response from National Fire Chiefs Council
Open published response
9 Dec 2024 Luke Marshall ALBISTON O'DONNELL · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2 Lack of public awareness of life-threatening risks from storing lithium iron battery appliances in domestic properties View source Lack of communication and media coverage about the dangers of storing electronic bikes and scooters in domestic properties 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
Luke Marshall ALBISTON O'DONNELL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Luke Marshall Albiston O'Donnell was an 8-year-old boy who died in hospital following a fire at his home. The fire began when an e-bike lithium battery ignited after coming into contact with combustible materials, and the battery-cell failure allowed the fire to develop rapidly. The report raises concerns that the public may not appreciate the life-threatening risks of storing e-bikes and similar appliances in domestic properties, and that communication about these dangers may be insufficient.
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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Lack of public awareness of life-threatening risks from storing lithium iron battery appliances in domestic properties
Wider context from the report “The general public do not appreciate the life-threatening risks involved with having lithium iron batteries, from electronic bikes in this case, stored in domestic properties. There appears to be a lack of communication/media coverage about the dangers involved with storing appliances such as electronic bikes/scooters in domestic properties. There have already been 3 deaths associated with lithium batteries in the home in Merseyside and we have been informed there a number of similar fatalities across England.
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Lack of communication and media coverage about the dangers of storing electronic bikes and scooters in domestic properties
Wider context from the report “The general public do not appreciate the life-threatening risks involved with having lithium iron batteries, from electronic bikes in this case, stored in domestic properties. There appears to be a lack of communication/media coverage about the dangers involved with storing appliances such as electronic bikes/scooters in domestic properties. There have already been 3 deaths associated with lithium batteries in the home in Merseyside and we have been informed there a number of similar fatalities across England.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reflect on national Home Safety Fire Prevention guidance and develop campaign resources addressing e-bike and e-scooter risks.
Verbatim wording from the response “In doing this, we will not only be able to share key learning points with UK fire and rescue services, but we will also be able to reflect on national Home Safety Fire Prevention guidance and develop our campaign resources. This will ensure that those who own or operate e-bikes or e-scooters are enabled to understand the risks and prevent similar incidents from occurring in their homes.” Source location Response from NFCC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Research e-bike and e-scooter fire risks with the ACER Group and international partners to identify existing evidence and knowledge gaps.
Verbatim wording from the response “As with all prevention activity, we recognise the significant challenge that fire and rescue services have in identifying and delivering behaviour changing interventions to individuals at risk. The growing market for e-bikes and e-scooters means that fire and rescue services are having to focus more resources to understand the demographics and behaviours of individuals that may be prone to these types of fires. To help fire and rescue services with this, we are looking to gain further understanding of the issues through more research. This includes working with our Academic Collaboration, Evaluation and Research (ACER)” Source location Response from NFCC
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inform all Chief Fire Officers about relevant incidents and existing resources, and request their support to raise awareness.
Verbatim wording from the response “Finally, I have taken the immediate step of writing to all Chief Fire Officers specifically to inform them of this and other incidents of this type, providing details of existing resources and the intentions of NFCC to explore further learning and resources. I have also requested their support to raise awareness.” Source location Response from NFCC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Charge Safe campaign providing e-bike and e-scooter charging advice and battery fire-hazard warnings.
Verbatim wording from the response “We recognise the seriousness and devastating impact that fires caused by lithium-ion batteries in electric scooters can cause to families across the UK and note the increasing occurrences of these types of incidents. We are committed to supporting the sector in delivering impactful prevention campaigns and initiatives. This includes our Charge Safe - NFCC campaign which sets out public advice for charging e-bikes and e-scooters as well as providing warning signs that a battery could be a fire hazard.” Source location Response from NFCC
Open published response
6 Dec 2024 Champagauri Bhatt and Dipak Bhatt · Prevention of Future Deaths report North London
View report summary
Concerns raised 8 Inadequate information management for analysis and learning from white goods fires View source Failure by fire-investigating companies to notify authorities of investigation outcomes View source Lack of sharing of recall and replacement decision data and rationale for condensate pumps and RFI filters View source Moisture ingress into condensate pumps causing tracking faults, resistive heating and fire View source Failure of product risk assessments to account for occupants and their actions View source Lack of sharing of warranty replacement data for condensate pumps and RFI filters View source Failure to provide fire-durable identification plates on appliances View source Inadequate manufacturing standards for mains- and sub-mains-operated condensate pumps and RFI filters View source See 5 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
Champagauri Bhatt and Dipak Bhatt · 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 29 March 2023, a fire caused by an electrical fault in a tumble dryer led to inhalation injuries and the deaths of Champagauri and Dipak Bhatt. Concerns included moisture ingress into condensate pumps causing faults and fire, and the need for improved data sharing, product safety standards, fire investigation reporting, risk assessment, and appliance identification.
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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate information management for analysis and learning from white goods fires
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires .
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Failure by fire-investigating companies to notify authorities of investigation outcomes
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations .
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Lack of sharing of recall and replacement decision data and rationale for condensate pumps and RFI filters
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Moisture ingress into condensate pumps causing tracking faults, resistive heating and fire
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire .
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Failure of product risk assessments to account for occupants and their actions
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates .
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Lack of sharing of warranty replacement data for condensate pumps and RFI filters
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters .
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide fire-durable identification plates on appliances
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate manufacturing standards for mains- and sub-mains-operated condensate pumps and RFI filters
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards .
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 Track Prevention of Future Deaths Reports and share them with NFCC members to identify and promote opportunities for improvement.
Verbatim wording from the response “Thank you for raising the concern in relation to the deaths of Champagauri and Dipak Bhatt on 29 March 2023. It is with great sadness that I read about the circumstances of their deaths. The National Fire Chiefs Council (NFCC) is committed to a culture of learning and improvement and seeks to support fire and rescue services (FRSs) to embed a learning culture. We actively track Prevention of Future Deaths Reports and share them with our members to ensure all opportunities for improvement are taken.” Source location Response from National Fire Chiefs Council
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 Receiving manufacturer information on recalled or warranty-replaced condensate pumps and FRI filters is outside the organisation’s remit.
Verbatim wording from the response “Unfortunately, this is not currently within the remit of NFCC. However, we do support the single recall register, which was a key output of the Total Recalls campaign initiated by London Fire Brigade and rolled out nationally. This was created as a consumer-facing initiative and focused on products rather than parts that could be causing issues across multiple appliances. This is recorded on a national register which can be found here: Product Safety Alerts, Reports and Recalls - GOV.UK” Source location Response from National Fire Chiefs Council
Open published response
8 Jun 2023 Ivan Rumenov Ignatov · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 5 Insufficient guidance for custody sergeants assessing detainee risk View source Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services View source Inaccessibility of post-release detainee information due to language or literacy barriers View source Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system View source Lack of guidance for releasing detainees without an address to reside at View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ivan Rumenov Ignatov · 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
Ivan Rumenov Ignatov entered the English Channel on 19 July 2020 and did not resurface; he was found deceased in the water on 31 July 2020. The report raises concerns about police risk assessment and recording, support for detainees released without accommodation or with language and literacy barriers, and communication between emergency and search-and-rescue services.
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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance for custody sergeants assessing detainee risk
Wider context from the report “ii. There is not sufficient guidance given to custody sergeants on a national basis of how to assess a person’s 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services
Wider context from the report “iv. There is a lack of knowledge and/or understanding amongst emergency services and search and rescue services, especially around terminology, process and communication for them to be able to work together when an incident arises without confusion or misunderstanding arising . I would request that consideration is given to further national and local training or guidance across emergency and search and rescue services to ensure communication can be facilitated without delay, and ensure terms and processes are understood to avoid any doubt of what action is being taken when an incident is ongoing.
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Inaccessibility of post-release detainee information due to language or literacy barriers
Wider context from the report “v. Leaflets given to detainees when released from police custody are not always accessible due to language or literacy barriers and I would request that consideration is given nationally by NHS England and all Police Forces to ensure that any documentation detainees, especially any providing help and assistance, is accessible to them.
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system
Wider context from the report “i. There is not sufficient clarity in the identifying, collating and recording of factors which may increase a person’s risk on the Niche system that Dorset Police, and other forces nationally, use and as a result information could be missed which is vital to a person’s risk assessment and their risk to themselves or others .
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for releasing detainees without an address to reside at
Wider context from the report “iii. There is no guidance, that I am aware of, which addresses what should be done by police forces, and particularly custody sergeants, when a person is to be released without an address to reside at and I would request consideration is given to such guidance being provided.
” 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 Continue encouraging fire and rescue services to follow existing JESIP doctrine and operational guidance.
Verbatim wording from the response “In response to the recommendations made the NFCC believes that appropriate guidance is available, and we will continue to encourage all FRSs to follow existing JESIP doctrine and operational guidance while continuing to develop existing guidance to make its application more effective.” Source location Response from National Fire Chiefs Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue developing existing operational guidance to make its application more effective.
Verbatim wording from the response “In response to the recommendations made the NFCC believes that appropriate guidance is available, and we will continue to encourage all FRSs to follow existing JESIP doctrine and operational guidance while continuing to develop existing guidance to make its application more effective.” Source location Response from National Fire Chiefs Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage with Dorset and Wiltshire Fire and Rescue Service to support effective multi-agency communication during incident response.
Verbatim wording from the response “The NFCC have engaged with Dorset and Wiltshire FRS. The JESIP principles are well embedded within their service. They lead on multi agency training and working closely with the Local Resilience Forum to embed effective multiagency communication during the response phase.” Source location Response from National Fire Chiefs Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing JESIP doctrine and NFCC operational guidance provide an appropriate response to interagency communication concerns, so no additional guidance is required.
Verbatim wording from the response “In response to the recommendations made the NFCC believes that appropriate guidance is available, and we will continue to encourage all FRSs to follow existing JESIP doctrine and operational guidance while continuing to develop existing guidance to make its application more effective.” Source location Response from National Fire Chiefs Council
Open published response
26 Apr 2022 Ashlie Timms · Prevention of Future Deaths report East London
View report summary
Concerns raised 7 Non-compliant fire alarms lacking automatic links to an Alarm Receiving Centre View source Lack of clear practical guidance for managing high-risk electrical devices in specialist housing View source Insufficient emphasis on British Standard recommendations for automatic fire alarm connections to Alarm Receiving Centres View source Incomplete fire safety audit processes View source Lack of clear guidance on fitting digital key-pad locks in specialist housing View source Failure of fire safety audits to accurately assess compliance View source Failure to ensure staff competence in fire evacuation procedures View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ashlie Timms · 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
Ashlie Timms, a 46-year-old woman living in supported accommodation, died on 20 April 2018 after a fire started when fabric materials came into contact with a portable fan heater. Staff delayed calling the emergency services, did not evacuate her, and the fire safety arrangements, alarm system, evacuation procedures and door lock were identified as concerns.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Non-compliant fire alarms lacking automatic links to an Alarm Receiving Centre
Wider context from the report “2. Fire Alarms in three units operated Sequence Care Group remain non-compliant with the 2013 British Standard Guidance , which recommends that they should have a link to an Alarm Receiving Centre (“ARC”) which automatically contacts the emergency services when a fire alarm is activated .
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear practical guidance for managing high-risk electrical devices in specialist housing
Wider context from the report “4. No clear and practical guidance exists on how specialist housing operators should manage the use of high-risk electrical devices such as portable electric fan heaters .
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient emphasis on British Standard recommendations for automatic fire alarm connections to Alarm Receiving Centres
Wider context from the report “6. Insufficient emphasis is placed upon recommendations contained within British Standards regarding automatic connections to ARCs in fire alarms fitted in specialist accommodation .
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Incomplete fire safety audit processes
Wider context from the report “3. The London Fire Brigade conducted fire safety audits at the premises which assessed the unit as displaying the highest standard of fire safety compliance. These findings were found to be entirely incongruent with procedures, equipment and staff training in place before and at the time of the fire. The London Fire Brigade have reviewed and changed processes since 2018 but they remain incomplete .
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on fitting digital key-pad locks in specialist housing
Wider context from the report “5. No clear guidance exists regarding the fitting of digital key-pad locks on doors in specialist housing .
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Failure of fire safety audits to accurately assess compliance
Wider context from the report “3. The London Fire Brigade conducted fire safety audits at the premises which assessed the unit as displaying the highest standard of fire safety compliance . These findings were found to be entirely incongruent with procedures, equipment and staff training in place before and at the time of the fire . The London Fire Brigade have reviewed and changed processes since 2018 but they remain incomplete.
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff competence in fire evacuation procedures
Wider context from the report “1. The operator of the premises failed to ensure that staff on duty were competent to carry out a fire evacuation . Despite reflection and remediation in policies, processes and training, multiple staff members who gave evidence to the inquest, remained unable to describe the proper action to take in the event of a fire alarm .
” 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 Lead the review of the competency framework for Fire Safety Regulators and the enforcement toolkit for high-rise buildings.
Verbatim wording from the response “1. The NFCC will redouble its efforts in progressing such work mentioned above and that it is responsible for. This extends to influencing the content of new or amended fire protection and safety standards. The NFCC is also currently leading the review of the competency framework for Fire Safety Regulators (which includes FRS inspecting and enforcement officers) and enforcement toolkit for high rise buildings and have in the past year launched a third-party professional accreditation scheme for Fire Safety Regulators and a national learning platform to underwrite the continual professional development of such officers.” Source location Response from National Fire Chiefs Council
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 Influence the content of new or amended fire protection and safety standards.
Verbatim wording from the response “1. The NFCC will redouble its efforts in progressing such work mentioned above and that it is responsible for. This extends to influencing the content of new or amended fire protection and safety standards. The NFCC is also currently leading the review of the competency framework for Fire Safety Regulators (which includes FRS inspecting and enforcement officers) and enforcement toolkit for high rise buildings and have in the past year launched a third-party professional accreditation scheme for Fire Safety Regulators and a national learning platform to underwrite the continual professional development of such officers.” Source location Response from National Fire Chiefs Council
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 Report the staff competency concern to relevant committees to encourage debate and pursue improved outcomes.
Verbatim wording from the response “The NFCC represent FRS on various British Standards Institute (BSI) committees and other groups such as National Social Housing Fire Safety Group.” Source location Response from National Fire Chiefs Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Home Office on guidance review and revision to address risks concerning high-risk electrical devices and digital keypad locks.
Verbatim wording from the response “Pursuant to Article 50 of the Order,¹¹ the Secretary of State must ensure that guidance (Guidance) is issued to assist those responsible for fire protection and fire safety within premises to which the Order applies. A full review and improvement of the Guidance is in progress and is being superintended by the Home Office.” Source location Response from National Fire Chiefs Council
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 Report the alarm connection concern to relevant British Standards committees to encourage debate and pursue improved outcomes.
Verbatim wording from the response “The NFCC represent FRS on BSI committees including the overarching committees for fire detection and alarm systems (FSH12) and fire precautions in buildings (FSH14).” Source location Response from National Fire Chiefs Council
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 Enforcement of fire safety regulations is outside the organisation’s functions because it is not an enforcing authority and has no regulatory functions.
Verbatim wording from the response “For the sake of clarity, the NFCC is not an enforcing authority under the principal fire regulations relevant to the premises in issue; it does not have regulatory functions.” Source location Response from National Fire Chiefs Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing specialised housing guide satisfactorily addresses risks associated with fitting digital keypad locks in specialist housing.
Verbatim wording from the response “5. No clear guidance exists regarding the fitting of digital key-pad locks on doors in specialist housing.” Source location Response from National Fire Chiefs Council
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 Dynamic sector scrutiny, review and reform prevent providing a definite timetable for completing the proposed standards and competency-related work.
Verbatim wording from the response “1. The NFCC will redouble its efforts in progressing such work mentioned above and that it is responsible for. This extends to influencing the content of new or amended fire protection and safety standards. The NFCC is also currently leading the review of the competency framework for Fire Safety Regulators (which includes FRS inspecting and enforcement officers) and enforcement toolkit for high rise buildings and have in the past year launched a third-party professional accreditation scheme for Fire Safety Regulators and a national learning platform to underwrite the continual professional development of such officers.” Source location Response from National Fire Chiefs Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing statutory care-home guidance and the specialised housing guide satisfactorily address risks from high-risk electrical devices.
Verbatim wording from the response “4. No clear and practical guidance exists on how specialist housing operators should manage the use of high-risk electrical devices such as portable electric fan heaters.” Source location Response from National Fire Chiefs Council
Open published response
21 Dec 2018 Ms Mihaela Lazar and Ms Dorina Zangari · Prevention of Future Deaths report London (East)
View report summary
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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 1 Fatalities and accidental injuries attributable to Bio Ethanol burners 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
Sharon Ann Soares and Blaise Sanito Alvares · 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
A fire broke out at 141 Manchester Road, Swindon, on 6 November 2016 after combustible materials were probably ignited by a bio ethanol heater. Sharon Ann Soares and Blaise Sanito Alvares were rescued but later died from injuries sustained in the fire. Evidence at the inquest indicated that this was at least the second occasion involving fatalities attributable to a bio ethanol burner, alongside previous accidental injuries.
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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Fatalities and accidental injuries attributable to Bio Ethanol burners
Wider context from the report “Evidence was heard at the inquest to the effect that this was at least the second occasion of fatalities attributable to a Bio Ethanol burner with a previous death reported in Uttoxeter, together with a substantial number of previous accidental injuries, including a series of events in Staffordshire .
” Open source report
Concerns raised 3 Highly flammable paraffin-based product with ignition risk View source Lack of fire-hazard warnings on E45 prescriptions and product packaging View source Failure to communicate E45 fire hazards by GPs 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
Michael Holyoake · 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
Michael Holyoake, who was bed bound with a terminal and inoperable brain tumour, died after a fire at his home while he was being cared for there. The fire was thought most likely to have involved his lighter and E45 emollient residue on his bedding and clothing, which acted as an accelerant. The principal concerns were a lack of awareness of E45’s flammability and the absence of fire hazard warnings on its prescription or packaging.
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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Highly flammable paraffin-based product with ignition risk
Wider context from the report “1. E45 is highly flammable as it is a paraffin based product, the residue of which acts as an accelerant. In this case there was a distinct lack of awareness of this fact, by the carers and the deceased. This was in part due to lack of communication by the GP but also due to the fact that there were no fire hazard warnings on the prescription or the product itself.
This product is widely available over the counter to the general public and commonly used for vulnerable individuals such as children and the elderly. Worryingly there would appear to be no warnings on the packaging that this is indeed highly flammable, with the potential risk of ignition .
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Lack of fire-hazard warnings on E45 prescriptions and product packaging
Wider context from the report “1. E45 is highly flammable as it is a paraffin based product, the residue of which acts as an accelerant. In this case there was a distinct lack of awareness of this fact, by the carers and the deceased. This was in part due to lack of communication by the GP but also due to the fact that there were no fire hazard warnings on the prescription or the product itself .
This product is widely available over the counter to the general public and commonly used for vulnerable individuals such as children and the elderly. Worryingly there would appear to be no warnings on the packaging that this is indeed highly flammable , with the potential risk of ignition.
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate E45 fire hazards by GPs
Wider context from the report “1. E45 is highly flammable as it is a paraffin based product, the residue of which acts as an accelerant. In this case there was a distinct lack of awareness of this fact, by the carers and the deceased. This was in part due to lack of communication by the GP but also due to the fact that there were no fire hazard warnings on the prescription or the product itself.
This product is widely available over the counter to the general public and commonly used for vulnerable individuals such as children and the elderly. Worryingly there would appear to be no warnings on the packaging that this is indeed highly flammable, with the potential risk of ignition.
” Open source report
Concerns raised 5 Failure to review and address fire risks of lower-paraffin emollient creams View source Lack of community information about paraffin-emollient ignition risk View source Fire hazard from paraffin-based emollients contacting clothing or dressings View source Failure to consider paraffin-emollient fire risk when prescribing View source Failure to communicate paraffin-emollient fire risk to patients View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Hills · 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 Hills, a resident of a nursing home, suffered fatal burns after his clothing and blankets caught fire while he was smoking in the conservatory. The report raised concerns about the failure to ensure he was wearing his fire-retardant apron and about insufficient awareness, communication and prevention of the fire risks associated with paraffin-based emollient creams such as Cetraben, particularly in community care settings.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Failure to review and address fire risks of lower-paraffin emollient creams
Wider context from the report “(5) The NPSA carried a Rapid Response Warning (and report) on 26 November 2007 providing background and recommendations on the use of paraffin based products, but focused (as does the BNF) on (non-proprietary emollient preparations, specifically) emulsifying ointments or 50% plus paraffin content emollients. It is not clear whether this has been recently reviewed or whether the potential risk of lower % paraffin content creams has been considered and addressed.
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Lack of community information about paraffin-emollient ignition risk
Wider context from the report “(7) Cetraben and Diprobase are proprietary emollient preparations in wide application in non-hospital environments, notably care homes, but also in private nursing and home care. It appears that there is little information conveyed or publicised about the potential risk of ignition/fire outside of hospitals or other clinical treatment areas , particularly where the cream is in frequent application and clothing (or bedding) has a high risk of becoming soaked or soiled by repeated application and contact.
(8) I am concerned about the potential risks associated with Cetraben (and associated lower % creams) and the level of awareness, communication and prevention of such risks in the community. I believe this should be considered, the risks assessed and action taken, as appropriate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Fire hazard from paraffin-based emollients contacting clothing or dressings
Wider context from the report “(2) Diprobase emollient cream (the next ‘greasy’ preparation product and next step up from Cetraben) contains 21% paraffin content (15% white soft paraffin and 6% liquid paraffin) but 7.2% alcohol, and carries a fire hazard warning on prescription: ‘Dressing and clothing in contact with this product are easily ignited by a naked flame – Keep away’ (the product bottle itself has not been examined for warnings during the course of my enquiries).
(3) The British National Formulary does not list either product specifically as being flammable, but does contain a general warning for paraffin based emollients that reads: “Fire hazard with paraffin-based emollients: Emulsifying ointment or 50% liquid paraffin and 50% white soft paraffin ointment in contact with dressings and clothing is easily ignited by a naked flame. The risk is greater when these preparations are applied to large areas of the body, and clothing or dressings become soaked with the ointment. Patients should be kept away from fire or flames and not to smoke when using these preparations. The risk of fire should be considered when using large quantities of any paraffin-based emollient”
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Failure to consider paraffin-emollient fire risk when prescribing
Wider context from the report “(4) Mr Hills was clearly recorded (in his medical notes) as being a chronic smoker with acute bronchitis. He was also recorded as being a pipe smoker (in his medical records on 13/10/14) yet had a repeat prescription for Cetraben 500 gram being recorded on 11/09/14. There is nothing to evidence that any risk was considered or communicated by either the GP surgery or the prescribing pharmacy.
” 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 National Fire Chiefs Council; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate paraffin-emollient fire risk to patients
Wider context from the report “(4) Mr Hills was clearly recorded (in his medical notes) as being a chronic smoker with acute bronchitis. He was also recorded as being a pipe smoker (in his medical records on 13/10/14) yet had a repeat prescription for Cetraben 500 gram being recorded on 11/09/14. There is nothing to evidence that any risk was considered or communicated by either the GP surgery or the prescribing pharmacy.
” 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.
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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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue engaging with DCLG’s working group to help develop the replacement Incident Recording System and improve collection, access and dissemination of appliance-fire information.
Verbatim wording from the response “As a result it may be possible to consider the ways that information is currently recorded and accessed thereby providing a more sustainable method to inform both TS and manufacturers of the information that you suggest on a regular basis. CFOA are already engaged with a working party developing the replacement IRS system, moreover there is an FISSG member to provide specific inputs on FRI related matters.” Source location 2014-0476-Response-by-Chief-Fire-Officers-Association
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Fire and Rescue Services with guidance to improve the accuracy and usefulness of Incident Recording System information by April 2015.
Verbatim wording from the response “3. CFOA will provide guidance to FRS by April 2015 to help ensure that the information provided on IRS is as accurate and meaningful as is possible to facilitate the ease by which DCLG could provide it to TS and manufacturers if they decided to do so.” Source location 2014-0476-Response-by-Chief-Fire-Officers-Association
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue engaging with BIS and provide CFOA support for developing web-based information sharing between Fire and Rescue Services and Trading Standards.
Verbatim wording from the response “In this respect, I can report that there has been work on going since early 2014, initiated by the aforementioned CFOA FISSG, to improve the ability for the FRS to share information and intelligence with TS. Following a meeting in June 2014, hosted by the Government’s Business Innovations and Skills Department (BIS), there was agreement by all stakeholders, including CFOA, the Department of Local Government (DCLG) and the Association of Trading Standards Officers (ACTSO) that information sharing between the FRS and TS was important and, as a result, BIS undertook to carry out exploratory research on how that might be achieved most effectively through web based means. CFOA continue to engage proactively on this project and are currently awaiting an update from BIS.” Source location 2014-0476-Response-by-Chief-Fire-Officers-Association
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 DCLG would be responsible for deciding whether meaningful information could be provided periodically to Trading Standards and manufacturers.
Verbatim wording from the response “All UK FRS provide information as to the cause of fires and the extent of damage caused by fire, to DCLG via their Incident Recording System (IRS). This is provided for every fire attended by the FRS and is generally gathered by frontline crews at the scene, rather than dedicated Fire Investigators who are mobilised depending on local circumstances but mostly where incidents are likely to be protracted or complicated. In respect to the subject matter, these routine reports will include the make and model of the appliance where that information is available. I have discussed the overlap between the two areas that we are responding to with ████████ and some of her colleagues. Whilst I am not in a position to comment upon the capacity for DCLG to change any processes, I do believe that there may be opportunities to work to enhance some of the information gathered for IRS.” Source location 2014-0476-Response-by-Chief-Fire-Officers-Association
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 Future levels of fire investigation by fire and rescue services cannot be guaranteed because legislation creates no specific investigation duty.
Verbatim wording from the response “As your letter relates to the sharing of information following investigations into the origin and cause of a fire, it is also important to note that whilst the Fire and Rescue Services Act 2004, in particular Section 45 of that Act, does give the FRS powers to obtain information and investigate fires, it does not place a specific duty on them to do so. Therefore, whilst all UK FRS currently investigate fires to an extent, it cannot be guaranteed in the absence of a statutory duty, the level that FRS will continue to investigate fires in the future.” Source location 2014-0476-Response-by-Chief-Fire-Officers-Association
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 CFOA cannot mandate or monitor UK fire and rescue services’ adoption of particular fire-investigation or information-sharing practices.
Verbatim wording from the response “CFOA is a charity whose purpose is to promote and increase efficiency amongst the UK’s Fire and Rescue Services (FRS) for the benefit of the public and all communities across the Country. It is important to note that my CFOA role does not authorise me to mandate any FRS to undertake a particular course of action. Whilst this is the case, I can produce guidance and recommend to the CFOA Board that this be issued to FRS in order to support the Association’s purpose.” Source location 2014-0476-Response-by-Chief-Fire-Officers-Association
Open published response
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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 National Fire Chiefs Council; 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 Chief Fire Officers Association, now represented here by National Fire Chiefs Council.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations