14 Dec 2018 BARNABY LUKE AYLWARD · Prevention of Future Deaths report West Yorkshire (West)
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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
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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.
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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 West Yorkshire Fire and Rescue Service; 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 West Yorkshire Fire and Rescue Service; 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 West Yorkshire Fire and Rescue Service; 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 West Yorkshire Fire and Rescue Service; 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 West Yorkshire Fire and Rescue Service; 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 West Yorkshire Fire and Rescue Service; 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 West Yorkshire Fire and Rescue Service; 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 West Yorkshire Fire and Rescue Service; 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
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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 Maintain responses to referrals concerning people identified as being at risk of fire in their homes.
Verbatim wording from the response “Finally, I am assured that our teams are working with partners across the five districts in the effort to provide our prevention services to those who most need it. We accept that there is still progress to be made around information governance and sharing data across organisational boundaries, and we will continue to make an appropriate response to all of the referrals that we receive in relation to people that are identified as being at risk of fire in their homes.” Source location 2018-0387-Responses
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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 Update the partnership agreement with South West Yorkshire Partnership NHS Foundation Trust.
Verbatim wording from the response “WYFRS has had a formal partnership in place with SWYFT for a number of years. There is a signed agreement dated October 2014 and we have been in the process of updating our partnership agreements following the introduction of the new Safer Communities Strategy in 2017. Our records show that WYFRS have received 86 referrals directly from SWYFT between 2016 and 2018. However, we expect the actual number of referrals from staff working across SWYFT to be higher than this figure as they may refer through their local team or department name but essentially their work falls under the SWYFT umbrella.” Source location 2018-0387-Responses
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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 Update the West Yorkshire partnership information-sharing agreement with Together Housing.
Verbatim wording from the response “WYFRS started communication with officials from Together Housing in July 2018 to establish a new partnership information sharing agreement to cover West Yorkshire, expanding the current arrangements. Discussions also took place about the development of training for personnel within both organisations to identify the support available within each service. WYFRS Demenia Resources were also shared with Together Housing to establish whether these would be suitable for their employees to support visits and aid the provision of key fire safety messages.” Source location 2018-0387-Responses
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations