PFD report

John NICHOLS · Prevention of Future Deaths report

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Issued 2 Nov 2017•Norfolk

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
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
8

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

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Concerns raised1

  1. Insufficient safeguards for monitoring residents, particularly those with dementia, before, during, and after fire drills
    Part of recurring concern: Failure to reliably monitor vulnerable residents during fire emergencies and drills
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.6

  1. Action

    Implement the fire consultant’s recommendations.

    Stated by Kings Lynn and Eastgate Residential Care HomesStated plannedThe respondent said that this action was planned when they made their response on 4 February 2018.
  2. Action

    Consult existing residents and their next of kin about assistance required during fire drills.

    Stated by Kings Lynn and Eastgate Residential Care HomesStated plannedThe respondent said that this action was planned when they made their response on 4 February 2018.
  3. Action

    Engage a fire consultant to observe and comment on the Group’s fire-drill procedures.

    Stated by Kings Lynn and Eastgate Residential Care HomesStated completedThe respondent said that this action was complete when they made their response on 4 February 2018.

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

Insufficient safeguards for monitoring residents, particularly those with dementia, before, during, and after fire drills

Wider context from the report

“That the Fire Drills Policy currently in place does not include sufficient safeguards to ensure that residents (and in particular those with dementia) are sufficiently monitored before, during, and after fire drills. ”

Is this part of a recurring concern?

Yes — Failure to reliably monitor vulnerable residents during fire emergencies and drills.

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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

Implement the fire consultant’s recommendations.

Verbatim wording from the response

“• We discussed the mistakes observed during the fire drill set out in the Fire Evacuation Record – Bay Tree Court (see Appendix 2) with SW and they were considered minor. We will implement his recommendations.”

Source location

2017-0344-Response-by-Kings-Lynn-and-Eastgate-Residential-Care-Homes
Page 2 · response
Published 4 February 2018

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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

Consult existing residents and their next of kin about assistance required during fire drills.

Verbatim wording from the response

“4. For those residents who have already been admitted into our homes we will, over the next few months, consult with next of kin and residents to see if they require assistance during a fire drill.”

Source location

2017-0344-Response-by-Kings-Lynn-and-Eastgate-Residential-Care-Homes
Page 3 · response
Published 4 February 2018

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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

Engage a fire consultant to observe and comment on the Group’s fire-drill procedures.

Verbatim wording from the response

“1. Engaged the services of Steve Wiltshire AIFSM (“SW”), a Fire Consultant to observe and comment on the Group’s fire drill procedures. We enclose a copy of his report for your consideration (“The Report”).”

Source location

2017-0344-Response-by-Kings-Lynn-and-Eastgate-Residential-Care-Homes
Page 2 · response
Published 4 February 2018

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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

Implement the amended Fire Drill Procedure across all homes, provide site-specific training, and reinforce the changes in annual fire-awareness updates.

Verbatim wording from the response

“5. [The Fire Drill Procedures have been amended to make clear that the answering of Nurscall bell continues as normal.] Consequently, we have amended the Group’s Fire Drill Procedure to reflect the changes to the above. This will be implemented across all the homes with the relevant training at each site. The annual Fire Awareness update will also re-iterate the changes made. We enclose a copy of the revised Fire Drill Procedure for your consideration (see Appendix 6).”

Source location

2017-0344-Response-by-Kings-Lynn-and-Eastgate-Residential-Care-Homes
Page 3 · response
Published 4 February 2018

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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

Conduct a further operational audit at Kings Lynn once the new procedures are embedded.

Verbatim wording from the response

“• We consider that the observation of the fire drill at Bay Tree Court, another of the Group’s homes of the same type as Kings Lynn Residential, was not a problem because the fire procedures are exactly the same across all the homes. When the new procedures are bedded in we will undertake an operational audit at Kings Lynn again.”

Source location

2017-0344-Response-by-Kings-Lynn-and-Eastgate-Residential-Care-Homes
Page 2 · response
Published 4 February 2018

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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 and amend the Group’s Fire Drill Procedure, Pre-Assessment Procedure and Personal Emergency Evacuation Plan to improve resident safety.

Verbatim wording from the response

“2. Internally reviewed and amended where necessary the Group’s Fire Drill Procedure, the Pre-Assessment Procedure and the Personal Emergency Evacuation Plan (“PEEP”) after carefully considering SW’s Report and reviewing the safety of the residents.”

Source location

2017-0344-Response-by-Kings-Lynn-and-Eastgate-Residential-Care-Homes
Page 2 · response
Published 4 February 2018

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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.2

  1. 1

    Monitor residents’ reactions to fire-alarm sounding during trial stays and adjust their PEEPs as required.

    Stated by Kings Lynn and Eastgate Residential Care HomesStated plannedThe respondent said that this action was planned when they made their response on 4 February 2018.
  2. 2

    Use the amended Pre-Assessment Form to enquire about distress caused by fire alarms before admission.

    Stated by Kings Lynn and Eastgate Residential Care HomesStated completedThe respondent said that this action was complete when they made their response on 4 February 2018.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.4

  1. 1

    Fire procedures are already incorporated into the fire risk assessments, including documented horizontal evacuation arrangements.

    Stated by Kings Lynn and Eastgate Residential Care HomesExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. 2

    The risk of physical harm from automatic fire-door closure is minimal because doors close in approximately twenty seconds.

    Stated by Kings Lynn and Eastgate Residential Care HomesDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  3. 3

    Residents’ bedroom fire doors are checked fortnightly to ensure they close and operate properly.

    Stated by Kings Lynn and Eastgate Residential Care HomesExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  4. 4

    Observing a fire drill at another group home was not problematic because fire procedures are identical across the homes.

    Stated by Kings Lynn and Eastgate Residential Care HomesDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Monitor residents’ reactions to fire-alarm sounding during trial stays and adjust their PEEPs as required.

Verbatim wording from the response

“3. During the trial period of a resident stay, we will monitor their reaction to the sounding of the fire alarm and adjust the PEEP as required. We enclose a copy of the revised PEEP for your consideration (see Appendix 5).”

Source location

2017-0344-Response-by-Kings-Lynn-and-Eastgate-Residential-Care-Homes
Page 2 · response
Published 4 February 2018

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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

Use the amended Pre-Assessment Form to enquire about distress caused by fire alarms before admission.

Verbatim wording from the response

“2. We consider that the issue of distress arising from the sounding of the fire alarm should be raised with the next of kin at the pre-assessment stage, before the person is admitted to the home. The alarm sounds regularly and should this cause distress, we may be unable to meet the needs of that person. We have amended the Pre-Assessment Form to make the proper enquiries. We enclose a copy of the new Pre-Assessment Form for your consideration (see Appendix 4).”

Source location

2017-0344-Response-by-Kings-Lynn-and-Eastgate-Residential-Care-Homes
Page 2 · response
Published 4 February 2018

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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

Fire procedures are already incorporated into the fire risk assessments, including documented horizontal evacuation arrangements.

Verbatim wording from the response

“• Horizontal evacuation is fully documented in the Fire Risk Assessments (“FRA”). A copy of the FRA for Kings Lynn is attached (Appendix 3). Please note that Kings Lynn Residential Home is a single storey building.”

Source location

2017-0344-Response-by-Kings-Lynn-and-Eastgate-Residential-Care-Homes
Page 2 · response
Published 4 February 2018

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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

The risk of physical harm from automatic fire-door closure is minimal because doors close in approximately twenty seconds.

Verbatim wording from the response

“2. The automatic closing of fire doors, which could cause distress. It should be noted that automatic closing of the fire doors takes approximately twenty seconds and the risk of physical harm is minimal. This time is based on a Doorguard being affixed.”

Source location

2017-0344-Response-by-Kings-Lynn-and-Eastgate-Residential-Care-Homes
Page 1 · response
Published 4 February 2018

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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

Residents’ bedroom fire doors are checked fortnightly to ensure they close and operate properly.

Verbatim wording from the response

“• Residents’ bedroom fire doors are checked on a fortnightly basis to ensure that they close and operate properly as part of the maintenance procedures at the homes. The correct closing of doors is important at all times and not just during fire drills.”

Source location

2017-0344-Response-by-Kings-Lynn-and-Eastgate-Residential-Care-Homes
Page 2 · response
Published 4 February 2018

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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

Observing a fire drill at another group home was not problematic because fire procedures are identical across the homes.

Verbatim wording from the response

“• We consider that the observation of the fire drill at Bay Tree Court, another of the Group’s homes of the same type as Kings Lynn Residential, was not a problem because the fire procedures are exactly the same across all the homes. When the new procedures are bedded in we will undertake an operational audit at Kings Lynn again.”

Source location

2017-0344-Response-by-Kings-Lynn-and-Eastgate-Residential-Care-Homes
Page 2 · response
Published 4 February 2018

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