PFD report

Andrew Robert Frank Clegg · Prevention of Future Deaths report

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Issued 1 Apr 2019•Wiltshire and Swindon

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
6

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Lack of inspector training to identify potential legionella infection risks
  2. Failure of care-home and healthcare-premises architects to take water safety into account
    Part of recurring concern: Inadequate control of waterborne pathogen risks in healthcare water systems
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Agree an updated memorandum with Public Health England to provide systematic access to water-safety technical expertise.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2019.
  2. Action

    Publish the interim Raising the Bar report proposing enhanced competence levels across relevant building and life-safety professions.

    Stated by Construction Industry CouncilStated plannedThe respondent said that this action was planned when they made their response on 9 June 2019.
  3. Action

    Develop and publish a concise member resource explaining the need to consider water safety when coordinating care-home and healthcare-building design.

    Stated by Royal Institute of British ArchitectsStated plannedThe respondent said that this action was planned when they made their response on 9 June 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Inspectors lack technical qualifications to advise providers on specific logistical water-safety issues.

    Stated by Care Quality CommissionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of inspector training to identify potential legionella infection risks

Wider context from the report

“2. Care homes and other healthcare premises are regularly inspected by the Care Quality Commission. In recent years the inspection regime has included a duty on inspectors to check on water safety. Expert evidence at the inquest suggested that inspectors lacked training to help them identify risks relating to potential legionella infection. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of care-home and healthcare-premises architects to take water safety into account

Wider context from the report

“1. Expert evidence suggested that architects designing care homes and healthcare premises, rarely take into account the need for water safety. In combating the risk of a proliferation of legionella bacteria, it is desirable, among other things, to design a water system with short pipe runs and with areas of maximum water usage established at the end of pipe runs to ensure a regular flushing of the pipework. Legionella bacteria, flourishing as it does at temperatures in excess of 20 degrees centigrade, precautions need to be taken to avoid heat exchange between hot and cold-water pipes, calling for cold-water pipes to be set at a distance from hot-water pipes rather than being run in parallel. ”

Is this part of a recurring concern?

Yes — Inadequate control of waterborne pathogen risks in healthcare water systems.

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

Agree an updated memorandum with Public Health England to provide systematic access to water-safety technical expertise.

Verbatim wording from the response

“CQC is currently in the process of agreeing an updated Memorandum of Understanding (MoU) with Public Health England (PHE) to improve CQC's access to water safety and water systems'-related technical expertise from PHE. Specific provision in the revised MoU is being made to regularise and make more systematic and efficient our access to PHE specialist expertise in circumstances where CQC require it to inform its regulatory functions. These functions include monitoring, inspection and civil and criminal enforcement actions. It is expected that the revised MoU will be agreed between CQC and PHE in summer of 2019.”

Source location

2019-0108-Responses
Page 3 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Publish the interim Raising the Bar report proposing enhanced competence levels across relevant building and life-safety professions.

Verbatim wording from the response

“Our report – Raising the Bar – proposes enhanced competence levels for Engineers, Installers, Fire Engineers, Fire Risk Assessors, Fire Safety Enforcement Officers, Building Control, Building Designers (including Architects), Building Safety Managers, Site Supervisors, Project Managers, Procurement and Products; and has been written with their direct participation and willingness to implement the new competence frameworks. The interim report is due to be published for consultation at the end of this month but, having worked closely with MHCLG and the Home Office throughout, the proposed recommendations dovetail with those included in Building A Safer Future: Proposals for reform of the building safety system.”

Source location

2019-0108-Responses
Page 7 · response
Published 9 June 2019

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 and publish a concise member resource explaining the need to consider water safety when coordinating care-home and healthcare-building design.

Verbatim wording from the response

“In responding to your concerns, the RIBA intends to develop a concise knowledge resource to explain to our members the need to consider water safety, particularly in coordinating the design of care homes and healthcare buildings. We intend to publish this as an article by the end of July to raise awareness of the water safety issues highlighted in your report.”

Source location

2019-0108-Responses
Page 4 · response
Published 9 June 2019

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

Inspectors lack technical qualifications to advise providers on specific logistical water-safety issues.

Verbatim wording from the response

“I would point out that CQC inspectors are not technically qualified in water safety or water systems generally (where these issues are known to develop) and therefore are unable to hold themselves out to be experts in this field. As a regulator we are not able or qualified to advise providers on how to deal with specific logistical water safety issues on site. We do however refer all providers to the relevant industry guidance on water safety as provided by the Health & Safety Executive. This can be found at http://www.hse.gov.uk/legionnaires and http://www.hse.gov.uk/pubns/books/l8.htm.”

Source location

2019-0108-Responses
Page 2 · response
Published 9 June 2019

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

Education, training, accreditation and continuing professional development for relevant designers fall outside the council’s direct remit and authority.

Verbatim wording from the response

“The first matter to report in response is that the Construction Industry Council does not have any locus or authority over the education, training, accreditation or continuing professional development of architects, construction (or building services) engineers or others designing water systems for care homes. And so, the particular action that you suggest in relation to providing relevant education and training for architects, construction (or building services) engineers or others designing water systems in this regard, is not within our direct remit but those of the relevant professional and training registration bodies. We will, of course, do what we can to encourage them to take the action suggested.”

Source location

2019-0108-Responses
Page 6 · response
Published 9 June 2019

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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

Technical examinations of water systems on registered provider sites are outside the regulatory inspection role.

Verbatim wording from the response

“It is the CQC’s responsibility to draw the providers attention to the expected compliance with these guidelines, it is not CQC’s role to make technical examinations of water systems on registered provider sites during inspections. It is the responsibility of the provider running the location to ensure they comply with the water safety guidelines and provide a safe environment for their service users.”

Source location

2019-0108-Responses
Page 2 · response
Published 9 June 2019

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

Relevant professional and training registration bodies are responsible for providing the suggested education and training.

Verbatim wording from the response

“The first matter to report in response is that the Construction Industry Council does not have any locus or authority over the education, training, accreditation or continuing professional development of architects, construction (or building services) engineers or others designing water systems for care homes. And so, the particular action that you suggest in relation to providing relevant education and training for architects, construction (or building services) engineers or others designing water systems in this regard, is not within our direct remit but those of the relevant professional and training registration bodies. We will, of course, do what we can to encourage them to take the action suggested.”

Source location

2019-0108-Responses
Page 6 · response
Published 9 June 2019

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Press for water safety to be included in the legislative package reforming the building-safety regulatory system.

    Stated by Construction Industry CouncilStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2019.
  2. 2

    Participate in the Independent Review of Building Regulations and Fire Safety and its competence-related work.

    Stated by Construction Industry CouncilStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  3. 3

    Work with government departments and others to support implementation of the Independent Review’s recommendations.

    Stated by Construction Industry CouncilStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2019.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Providers are responsible for complying with water-safety guidance and ensuring safe environments for service users.

    Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Press for water safety to be included in the legislative package reforming the building-safety regulatory system.

Verbatim wording from the response

“The key issue here is that the initial focus of the Hackitt Review was very much on fire safety, following on from the Grenfell tragedy, but we have pushed for this to be increased to all aspects of life safety. In its proposals, the government has accepted the argument that matters of structural safety are to be included within the legislative package for reform of the building safety regulatory system, but not water safety. We are continuing to press this point and your Investigation Report into the tragic death of Mr Clegg is timely to help us ensure that ALL aspects of life safety are considered in this package of reforms.”

Source location

2019-0108-Responses
Page 7 · response
Published 9 June 2019

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

Participate in the Independent Review of Building Regulations and Fire Safety and its competence-related work.

Verbatim wording from the response

“We are deeply involved in the very necessary work that is required in the post-Grenfell improvement of life safety competences for all those who commission, design, construct, maintain and manage higher risk residential buildings. We have actively participated in the Independent Review of the Building Regulations and Fire Safety, carried out by Dame Judith Hackitt – I was privileged to serve her Review as Chair of the Competence working group. We fully support the outcome of that review, Building A Safer Future, which was published in May 2018 and have been working with the MHCLG, the Home Office and others to ensure that Dame Judith’s recommendations are implemented.”

Source location

2019-0108-Responses
Page 6 · response
Published 9 June 2019

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 government departments and others to support implementation of the Independent Review’s recommendations.

Verbatim wording from the response

“We are deeply involved in the very necessary work that is required in the post-Grenfell improvement of life safety competences for all those who commission, design, construct, maintain and manage higher risk residential buildings. We have actively participated in the Independent Review of the Building Regulations and Fire Safety, carried out by Dame Judith Hackitt – I was privileged to serve her Review as Chair of the Competence working group. We fully support the outcome of that review, Building A Safer Future, which was published in May 2018 and have been working with the MHCLG, the Home Office and others to ensure that Dame Judith’s recommendations are implemented.”

Source location

2019-0108-Responses
Page 6 · response
Published 9 June 2019

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

Providers are responsible for complying with water-safety guidance and ensuring safe environments for service users.

Verbatim wording from the response

“It is the CQC’s responsibility to draw the providers attention to the expected compliance with these guidelines, it is not CQC’s role to make technical examinations of water systems on registered provider sites during inspections. It is the responsibility of the provider running the location to ensure they comply with the water safety guidelines and provide a safe environment for their service users.”

Source location

2019-0108-Responses
Page 2 · response
Published 9 June 2019

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026