Recipient name withheld

Pin Request correction

First report 24 Apr 2023•Latest report 24 Apr 2023

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Recipient name withheld linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Avon

    AI-generated summary

    Christopher Evans · 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

    Christopher Evans, who was vulnerable and had physical health problems, was found unresponsive and almost completely submerged in a bath of very hot water on 28 September 2020 and was pronounced dead at the scene. The report identified concerns that his supported accommodation was not subject to CQC or HSE oversight and that the regulatory framework did not require assessment or management of scalding risks or provision of engineering controls for vulnerable residents.

    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a requirement to assess and manage scalding risk in HMOs accommodating vulnerable persons

    Wider context from the report

    “(1) Mr. Evans resided in supported accommodation which was appropriately licensed as an HMO. The provision and maintenance of services, including electricity, gas and water was the responsibility of Supported Independence Limited. However, the HMO licence did not require there be thermostatic control valves fitted to the hot water taps in the Deceased's flat. (2) Since the Deceased resided in his own accommodation and was not provided with a regulated activity, the accommodation was not regulated nor subject to inspection by the CQC. (3) Similarly the HSE had no authority to inspect premises under the Health and Safety at Work Act 1974 as the Deceased resided in his own home. (4) If the Deceased, who was vulnerable, had resided in health and social care premises then there would have been a requirement to assess the risk of scalding and burning in the context of his vulnerability. (5) Engineering controls could then have been provided to minimise the risk of scalding particularly where there is whole body immersion. (6) In accommodating vulnerable persons in such an HMO there appears to be a deficiency in the regulatory framework in that there is no requirement to assess and manage the risk of scalding and no overview by any regulatory body. ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a requirement for thermostatic control valves on hot water taps in supported accommodation

    Wider context from the report

    “(1) Mr. Evans resided in supported accommodation which was appropriately licensed as an HMO. The provision and maintenance of services, including electricity, gas and water was the responsibility of Supported Independence Limited. However, the HMO licence did not require there be thermostatic control valves fitted to the hot water taps in the Deceased's flat. (2) Since the Deceased resided in his own accommodation and was not provided with a regulated activity, the accommodation was not regulated nor subject to inspection by the CQC. (3) Similarly the HSE had no authority to inspect premises under the Health and Safety at Work Act 1974 as the Deceased resided in his own home. (4) If the Deceased, who was vulnerable, had resided in health and social care premises then there would have been a requirement to assess the risk of scalding and burning in the context of his vulnerability. (5) Engineering controls could then have been provided to minimise the risk of scalding particularly where there is whole body immersion. (6) In accommodating vulnerable persons in such an HMO there appears to be a deficiency in the regulatory framework in that there is no requirement to assess and manage the risk of scalding and no overview by any regulatory body. ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of regulatory oversight and inspection of HMOs accommodating vulnerable persons

    Wider context from the report

    “(1) Mr. Evans resided in supported accommodation which was appropriately licensed as an HMO. The provision and maintenance of services, including electricity, gas and water was the responsibility of Supported Independence Limited. However, the HMO licence did not require there be thermostatic control valves fitted to the hot water taps in the Deceased's flat. (2) Since the Deceased resided in his own accommodation and was not provided with a regulated activity, the accommodation was not regulated nor subject to inspection by the CQC. (3) Similarly the HSE had no authority to inspect premises under the Health and Safety at Work Act 1974 as the Deceased resided in his own home. (4) If the Deceased, who was vulnerable, had resided in health and social care premises then there would have been a requirement to assess the risk of scalding and burning in the context of his vulnerability. (5) Engineering controls could then have been provided to minimise the risk of scalding particularly where there is whole body immersion. (6) In accommodating vulnerable persons in such an HMO there appears to be a deficiency in the regulatory framework in that there is no requirement to assess and manage the risk of scalding and no overview by any regulatory body. ”
    Open source report
Back to top

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026