PFD report

Christopher John Butler · Prevention of Future Deaths report

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Issued 24 Feb 2015•Oxfordshire

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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
13

Described in responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Report evidence summary

Concerns raised1

  1. Potential presence of latent wiring faults in similar properties
    Part of recurring concern: Uncontrolled hazards from defective electrical wiring and installations
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.2

  1. Action

    Publish and provide a case study of the fire to NICEIC and the Electrical Safety Council for electrician education.

    Stated by Oxfordshire County Council Fire and Rescue ServiceStated plannedThe respondent said that this action was planned when they made their response on 24 February 2015.
  2. Action

    Review property information to identify the house builder and assess local or national fire trends associated with it.

    Stated by Oxfordshire County Council Fire and Rescue ServiceStated in progressThe respondent said that this action was in progress when they made their response on 24 February 2015.

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

Potential presence of latent wiring faults in similar properties

Wider context from the report

“The fault in the wiring that resulted in this fire may be present in other similar properties within the estate built at the same time. Electric testing will not necessarily reveal this fault. ”

Is this part of a recurring concern?

Yes — Uncontrolled hazards from defective electrical wiring and installations.

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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

Publish and provide a case study of the fire to NICEIC and the Electrical Safety Council for electrician education.

Verbatim wording from the response

“The outcome of the fire investigation in this specific case identified that the direct cause of the fire was attributed to an overheated cable caused by a sharp ninety degree bend in the wire probably formed during the installation stage. This could be replicated and present in many other internal wiring situations both locally and nationally. We will shortly be publishing and providing a case study concerning this specific incident to the National Inspection Council for Electrical Installation Contracting (NICEIC) and the Electrical Safety Council to enable them to use it in the education of electricians around the country.”

Source location

2015-0482-Response-by-Oxfordshire-County-Council
Page 2 · response
Published 24 February 2015

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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

Review property information to identify the house builder and assess local or national fire trends associated with it.

Verbatim wording from the response

“• We are reviewing the property information to determine who the house builder was and whether there have been any local or national trends of fires with this organisation and will take further action as appropriate to our findings”

Source location

2015-0482-Response-by-Oxfordshire-County-Council
Page 2 · response
Published 24 February 2015

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.11

  1. 1

    Review stakeholder partnership arrangements and improve structured sharing of intelligence about risks affecting vulnerable people.

    Stated by Oxfordshire County Council Fire and Rescue ServiceStated in progressThe respondent said that this action was in progress when they made their response on 24 February 2015.
  2. 2

    Share the fire’s circumstances and subsequent actions with 51 fire and rescue services through the Chief Fire Officers Association.

    Stated by Oxfordshire County Council Fire and Rescue ServiceStated plannedThe respondent said that this action was planned when they made their response on 24 February 2015.
  3. 3

    Identify local communication channels for disseminating fire and electrical safety advice.

    Stated by Oxfordshire County Council Fire and Rescue ServiceStated completedThe respondent said that this action was complete when they made their response on 24 February 2015.
  4. 4

    Release electrical fire safety information and update public websites to promote home electrical testing and modern fuse-box safety benefits.

    Stated by Oxfordshire County Council Fire and Rescue ServiceStated completedThe respondent said that this action was complete when they made their response on 24 February 2015.
  5. 5

    Review the Near Miss and Fatal Incident Review process with Adults and Social Services to strengthen organisational and sector-wide learning.

    Stated by Oxfordshire County Council Fire and Rescue ServiceStated in progressThe respondent said that this action was in progress when they made their response on 24 February 2015.
  6. 6

    Work with Electrical Safety First to provide residents with an electrical safety booklet and signpost recognised electricians.

    Stated by Oxfordshire County Council Fire and Rescue ServiceStated in progressThe respondent said that this action was in progress when they made their response on 24 February 2015.
  7. 7

    Write to residents of comparable properties and provide additional preventative information about the fatal incident.

    Stated by Oxfordshire County Council Fire and Rescue ServiceStated completedThe respondent said that this action was complete when they made their response on 24 February 2015.
  8. 8

    Identify vulnerable residents in the targeted area through council social-care links to enable further personal assistance.

    Stated by Oxfordshire County Council Fire and Rescue ServiceStated completedThe respondent said that this action was complete when they made their response on 24 February 2015.
  9. 9

    Develop and initiate earlier critical reviews of significant ‘persons reported’ incidents to support internal, external and coronial investigations and wider learning.

    Stated by Oxfordshire County Council Fire and Rescue ServiceStated in progressThe respondent said that this action was in progress when they made their response on 24 February 2015.
  10. 10

    Complete a comprehensive review of the circumstances and challenge how community risks are identified, managed and addressed.

    Stated by Oxfordshire County Council Fire and Rescue ServiceStated completedThe respondent said that this action was complete when they made their response on 24 February 2015.
  11. 11

    Review and improve processes for investigating and understanding future tragic incidents using the HSG65 Plan, Do, Check and Act model.

    Stated by Oxfordshire County Council Fire and Rescue ServiceStated in progressThe respondent said that this action was in progress when they made their response on 24 February 2015.

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

Review stakeholder partnership arrangements and improve structured sharing of intelligence about risks affecting vulnerable people.

Verbatim wording from the response

“I have asked my Home and Community Safety Team to review the partnership arrangements in place across all stakeholders that came into contact with Mr Butler and identify if any concerns around risk were known and flagged to relevant stakeholders. This will ensure future”

Source location

2015-0482-Response-by-Oxfordshire-County-Council
Page 1 · response
Published 24 February 2015

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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 fire’s circumstances and subsequent actions with 51 fire and rescue services through the Chief Fire Officers Association.

Verbatim wording from the response

“As fire and rescue services, we continually learn from each other following tragic and unusual incidents such as this and we will share the circumstances of the cause of this fire and the subsequent actions with 51 fire and rescue services via the Chief Fire Officers Association.”

Source location

2015-0482-Response-by-Oxfordshire-County-Council
Page 2 · response
Published 24 February 2015

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

Identify local communication channels for disseminating fire and electrical safety advice.

Verbatim wording from the response

“• We have identified a number of other local information avenues, for example Parish newsletters and residents groups to communicate fire safety advice and specifically some electrical fire safety advice”

Source location

2015-0482-Response-by-Oxfordshire-County-Council
Page 2 · response
Published 24 February 2015

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

Release electrical fire safety information and update public websites to promote home electrical testing and modern fuse-box safety benefits.

Verbatim wording from the response

“• We have released a general electrical fire safety press release and updated our public websites to raise the awareness and target home electrical testing including the safety benefits and importance of modern fuse box designs.”

Source location

2015-0482-Response-by-Oxfordshire-County-Council
Page 2 · response
Published 24 February 2015

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

Review the Near Miss and Fatal Incident Review process with Adults and Social Services to strengthen organisational and sector-wide learning.

Verbatim wording from the response

“• We are also working with Adults and Social Services to review our Near Miss and Fatal Incident Review process in order to ensure our future approach is comprehensive and will deliver internal reflective learning and offer best practice within the organisation and to the wider fire sector”

Source location

2015-0482-Response-by-Oxfordshire-County-Council
Page 2 · response
Published 24 February 2015

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 Electrical Safety First to provide residents with an electrical safety booklet and signpost recognised electricians.

Verbatim wording from the response

“• We are also working with Electrical Safety First in order to provide these residents with a comprehensive home electrical safety booklet plus we are signposting them to recognised electricians via the OCC Trading Standards ‘Trust a Trader’ list if they needed some further expert advice”

Source location

2015-0482-Response-by-Oxfordshire-County-Council
Page 2 · response
Published 24 February 2015

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

Write to residents of comparable properties and provide additional preventative information about the fatal incident.

Verbatim wording from the response

“I have also asked our OCCFRS Home and Community Safety Team to inform and educate residents in the local area and as a result the following activities are being undertaken:”

Source location

2015-0482-Response-by-Oxfordshire-County-Council
Page 2 · response
Published 24 February 2015

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

Identify vulnerable residents in the targeted area through council social-care links to enable further personal assistance.

Verbatim wording from the response

“• We have utilised our close links with Oxfordshire County Council’s Social and Community Services in order to identify any specific vulnerable residents within this targeted area in order to provide further personal assistance to them”

Source location

2015-0482-Response-by-Oxfordshire-County-Council
Page 2 · response
Published 24 February 2015

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 initiate earlier critical reviews of significant ‘persons reported’ incidents to support internal, external and coronial investigations and wider learning.

Verbatim wording from the response

“We are also making improvements and reviewing our approach to incidents of this type to ensure that a critical review of our risk management is carried out earlier in order to inform any internal or external agency investigation or Coroner’s Hearing. This new approach will be initiated for all significant “persons reported” (where a life is considered to be in the property) incidents so we can learn from a wider number of incidents which had the potential to lead to a fire fatality. This will enable us to identify the risk factors beyond those that we currently scrutinise and share this with the wider fire sector regionally and nationally.”

Source location

2015-0482-Response-by-Oxfordshire-County-Council
Page 2 · response
Published 24 February 2015

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

Complete a comprehensive review of the circumstances and challenge how community risks are identified, managed and addressed.

Verbatim wording from the response

“Following the receipt of your letter Oxfordshire County Council Fire and Rescue Service (OCCFRS) has undertaken a comprehensive review of the circumstances relating to this case. We have taken this opportunity to further challenge how we identify, manage and deal with risk in the community. We are also reviewing how to further improve our processes concerning investigating and fully understanding the circumstances to a future tragic incident. We consider that this approach will enable further information to support all investigations into the cause of the fire and also the wider causation that lead to these fatal events.”

Source location

2015-0482-Response-by-Oxfordshire-County-Council
Page 1 · response
Published 24 February 2015

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

Review and improve processes for investigating and understanding future tragic incidents using the HSG65 Plan, Do, Check and Act model.

Verbatim wording from the response

“Following the receipt of your letter Oxfordshire County Council Fire and Rescue Service (OCCFRS) has undertaken a comprehensive review of the circumstances relating to this case. We have taken this opportunity to further challenge how we identify, manage and deal with risk in the community. We are also reviewing how to further improve our processes concerning investigating and fully understanding the circumstances to a future tragic incident. We consider that this approach will enable further information to support all investigations into the cause of the fire and also the wider causation that lead to these fatal events.”

Source location

2015-0482-Response-by-Oxfordshire-County-Council
Page 1 · response
Published 24 February 2015

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

Official responses located
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Data last updated 7 September 2026