14 Dec 2018 BARNABY LUKE AYLWARD · Prevention of Future Deaths report West Yorkshire (West)
View report summary
Concerns raised 8 Failure to share relevant risk information between agencies View source Failure to conduct regular multi-agency preventative review and reassessment of fire risks View source Failure to carry out regular property inspections and provide assistance View source Failure to record significant clutter and associated risk in clinical notes View source Lack of collective or assigned responsibility for reducing home fire risk View source Limited efforts to extend practical and financial support through family members View source Failure of care plan documentation to record behavioural fire risks and planned review View source Failure to facilitate private professional discussion during risk management and MHA assessment View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
BARNABY LUKE AYLWARD · 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
Barnaby Luke Aylward died in the early hours of 4 September 2017 after being overcome by smoke from an accidental house fire caused more likely than not by a lit cigarette. The report identified concerns about known fire risks associated with his heavy smoking, clutter and serious mental illness, including insufficient multi-agency risk assessment, information sharing, property inspection, care planning and preventative support.
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 Together Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant risk information between agencies
Wider context from the report “(1) Mr Aylward was a social housing tenant. He exhibited certain behaviours that were in part linked to his serious mental illness. Those presented risk of death in a fire at home including heavy smoking and allowing clutter and waste to accumulate there. Those behaviours and thus the risks were known to certain individuals, including his family, and agencies but they did not except in time of crisis or emergency:
a) review those potential risks with a multi agency preventative approach and re assess those risks regularly over time;
b) take any collective responsibility nor for any one person or agency to take responsibility to reduce or eliminate risk by action eg clearing clutter and fire risk; and education about risk and reluctance to compel Mr Aylward to improve his environment regularly if needed;
c) did not feel empowered to make property inspections regularly or at all and advise Mr Aylward and other agencies, or have sufficient resources at the right level to inspect and assist;
d) may have been hampered by issues of confidentiality in communications between agencies .
If all agencies had shared the particulars of his behaviours the burden of risk might be shared and understood and potential to reduce or eliminate the risk attempted, reviewed and managed.
” 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 Together Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct regular multi-agency preventative review and reassessment of fire risks
Wider context from the report “(1) Mr Aylward was a social housing tenant. He exhibited certain behaviours that were in part linked to his serious mental illness. Those presented risk of death in a fire at home including heavy smoking and allowing clutter and waste to accumulate there. Those behaviours and thus the risks were known to certain individuals, including his family, and agencies but they did not except in time of crisis or emergency:
a) review those potential risks with a multi agency preventative approach and re assess those risks regularly over time ;
b) take any collective responsibility nor for any one person or agency to take responsibility to reduce or eliminate risk by action eg clearing clutter and fire risk; and education about risk and reluctance to compel Mr Aylward to improve his environment regularly if needed;
c) did not feel empowered to make property inspections regularly or at all and advise Mr Aylward and other agencies, or have sufficient resources at the right level to inspect and assist;
d) may have been hampered by issues of confidentiality in communications between agencies.
If all agencies had shared the particulars of his behaviours the burden of risk might be shared and understood and potential to reduce or eliminate the risk attempted, reviewed and managed.
” 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 Together Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out regular property inspections and provide assistance
Wider context from the report “(1) Mr Aylward was a social housing tenant. He exhibited certain behaviours that were in part linked to his serious mental illness. Those presented risk of death in a fire at home including heavy smoking and allowing clutter and waste to accumulate there. Those behaviours and thus the risks were known to certain individuals, including his family, and agencies but they did not except in time of crisis or emergency:
a) review those potential risks with a multi agency preventative approach and re assess those risks regularly over time;
b) take any collective responsibility nor for any one person or agency to take responsibility to reduce or eliminate risk by action eg clearing clutter and fire risk; and education about risk and reluctance to compel Mr Aylward to improve his environment regularly if needed;
c) did not feel empowered to make property inspections regularly or at all and advise Mr Aylward and other agencies, or have sufficient resources at the right level to inspect and assist ;
d) may have been hampered by issues of confidentiality in communications between agencies.
If all agencies had shared the particulars of his behaviours the burden of risk might be shared and understood and potential to reduce or eliminate the risk attempted, reviewed and managed.
” 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 Together Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record significant clutter and associated risk in clinical notes
Wider context from the report “(3) The presence of clutter and thus risk was not always evidenced in other clinical notes as a symptom of Mr Aylward's illness of significance as were other presentations of his illness.
” 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 Together Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of collective or assigned responsibility for reducing home fire risk
Wider context from the report “(1) Mr Aylward was a social housing tenant. He exhibited certain behaviours that were in part linked to his serious mental illness. Those presented risk of death in a fire at home including heavy smoking and allowing clutter and waste to accumulate there. Those behaviours and thus the risks were known to certain individuals, including his family, and agencies but they did not except in time of crisis or emergency:
a) review those potential risks with a multi agency preventative approach and re assess those risks regularly over time;
b) take any collective responsibility nor for any one person or agency to take responsibility to reduce or eliminate risk by action eg clearing clutter and fire risk; and education about risk and reluctance to compel Mr Aylward to improve his environment regularly if needed ;
c) did not feel empowered to make property inspections regularly or at all and advise Mr Aylward and other agencies, or have sufficient resources at the right level to inspect and assist;
d) may have been hampered by issues of confidentiality in communications between agencies.
If all agencies had shared the particulars of his behaviours the burden of risk might be shared and understood and potential to reduce or eliminate the risk attempted, reviewed and managed.
” 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 Together Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Limited efforts to extend practical and financial support through family members
Wider context from the report “(4) There was some but not much evidence of seeking to extend support to Mr Aylward through his family members including practical and financial help.
” 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 Together Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of care plan documentation to record behavioural fire risks and planned review
Wider context from the report “(2) The mental health care delivered to Mr Aylward was within a Care Planning Approach. The Care Plan documentation did not identify his above behaviours in writing and thus potential risks, nor indicate review and solutions including with housing provision
” 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 Together Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to facilitate private professional discussion during risk management and MHA assessment
Wider context from the report “(5) The appropriateness for a risk management meeting and also MHA assessment in part to be held away from the patient to enable frank discussions to take place between mental health professionals rather than in front of the patient perhaps more robust views may not have been enabled .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the partnership agreement with West Yorkshire Fire and Rescue Service to include an information-sharing protocol.
Verbatim wording from the response “5.3 Partnership Agreement with West Yorkshire Fire and Rescue Service – the existing agreement with Together Housing and WYF&R service has been updated and includes an” Source location 2018-0387-Responses
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 Resume regular tenancy audits focused on tenants with no recent contact or identified vulnerability, including property inspections where access is permitted.
Verbatim wording from the response “4.2 Tenancy Audits - From April 2019 we are resuming regular visits to tenants, this programme of visits will focus on those where we have had no previous contact (eg via repairs or gas servicing) or have had concerns regarding vulnerability. These will include a property inspection where tenants will allow access. Any issues of concern will be acted upon via tenancy safeguarding procedures.” Source location 2018-0387-Responses
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 Assign the Fire Safety Group responsibility for monitoring, learning lessons and making risk-reduction policy decisions.
Verbatim wording from the response “3.4 Strategic Fire Safety Group - The existing Fire Safety Group will take responsibility for monitoring, learning lessons and taking policy decisions where appropriate to reduce risks. The group consists of officers from across the Together Housing Group alongside representatives from the West Yorkshire Fire and Rescue Service.” Source location 2018-0387-Responses
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 Develop a vulnerability database to identify higher-risk tenants and update relevant information annually and at key tenancy or safeguarding points.
Verbatim wording from the response “3.1 Information about our customers - We are developing further our database in relation to vulnerabilities including those related to fire risks. Annually we will update personal information from higher risk customers particularly those in supported housing and high rise flats. This database is aimed at ensuring we identify higher risk tenants and causes, it requests details on health and lifestyle issues. We request this data from tenants and where appropriate arrange joint safe and well visits with the fire service. The information is updated annually but also used at the start of new tenancies or where officers identify a safeguarding issue with a tenant.” Source location 2018-0387-Responses
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 Amend the hoarding procedure and link it to local arrangements, including the Kirklees Hoarding Panel.
Verbatim wording from the response “3.5 Hoarding - We have introduced a new approach to hoarding and all relevant colleagues have now undergone training in how to recognise and deal with tenants in these situations. We will by the end of March 2019 have amended the hoarding procedure and included links to local arrangements including the Kirklees Hoarding panel.” Source location 2018-0387-Responses
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations