PFD report

Janet Shirley Jasper · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 17 Jan 2020•Rutland and North Leicestershire

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
5

Named on the report

Responses found
6

Of 5 recipients

Stated actions
6

Described in responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Report evidence summary

Concerns raised2

  1. Inconsistent inspection of adjoining properties for gas
    Part of recurring concern: Unreliable gas safety inspection arrangements
  2. Risk of floors failing in properties within the immediate area
    Part of recurring concern: Uncontrolled structural-collapse risks in properties
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.5

  1. Action

    Put the revised investigation requirements in place across all gas distribution networks.

    Stated by Cadent Gas Limited and Northern Gas Networks Limited and Scotland Gas Networks plc and Southern Gas Networks PLC and Wales & West Utilities LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 February 2020.
  2. Action

    Brief operational teams on the revised internal-gas-escape investigation requirements.

    Stated by Cadent Gas Limited and Northern Gas Networks Limited and Scotland Gas Networks plc and Southern Gas Networks PLC and Wales & West Utilities LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 February 2020.
  3. Action

    Agree aligned wording clarifying requirements for investigating internal gas escapes and checking possible external sources.

    Stated by Cadent Gas Limited and Northern Gas Networks Limited and Scotland Gas Networks plc and Southern Gas Networks PLC and Wales & West Utilities LimitedStated completedThe respondent said that this action was complete when they made their response on 8 February 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The HSE would separately consider action concerning the 254 properties at risk of floor failure.

    Stated by Cadent Gas Limited and Northern Gas Networks Limited and Scotland Gas Networks plc and Southern Gas Networks PLC and Wales & West Utilities LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Inconsistent inspection of adjoining properties for gas

Wider context from the report

“The Court heard that there are two hundred and fifty four properties within the immediate area of the incident which are at risk of floors failing in a similar manner The Court also heard there is inconsistency in the policies of the four gas distribution networks with some requiring first call operatives to inspect adjoining properties for gas and some permitting the operative to make that decision based upon the circumstance and findings on scene In my opinion there is a risk that future deaths may occur unless the risk to the other properties within the immediate area of the incident is properly and quickly addressed, and a consistent approach to inspecting adjoining properties is developed ”

Is this part of a recurring concern?

Yes — Unreliable gas safety inspection arrangements.

Open source report

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

Risk of floors failing in properties within the immediate area

Wider context from the report

“The Court heard that there are two hundred and fifty four properties within the immediate area of the incident which are at risk of floors failing in a similar manner The Court also heard there is inconsistency in the policies of the four gas distribution networks with some requiring first call operatives to inspect adjoining properties for gas and some permitting the operative to make that decision based upon the circumstance and findings on scene In my opinion there is a risk that future deaths may occur unless the risk to the other properties within the immediate area of the incident is properly and quickly addressed, and a consistent approach to inspecting adjoining properties is developed ”

Is this part of a recurring concern?

Yes — Uncontrolled structural-collapse risks in properties.

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

Put the revised investigation requirements in place across all gas distribution networks.

Verbatim wording from the response

“investigate the possibility of gas leaking from external sources before confirming a “no trace” result. As part of this investigation, operatives must check immediately adjoining and adjacent properties where it could be reasonably assumed, based on site conditions, that they are a possible cause of the reported smell of gas.”

Source location

Response from Cadent Gas, Northern Gas, Scotland Gas Wales and West Utilities
Page 2 · response
Published 8 February 2020

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

Brief operational teams on the revised internal-gas-escape investigation requirements.

Verbatim wording from the response

“investigate the possibility of gas leaking from external sources before confirming a “no trace” result. As part of this investigation, operatives must check immediately adjoining and adjacent properties where it could be reasonably assumed, based on site conditions, that they are a possible cause of the reported smell of gas.”

Source location

Response from Cadent Gas, Northern Gas, Scotland Gas Wales and West Utilities
Page 2 · response
Published 8 February 2020

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

Agree aligned wording clarifying requirements for investigating internal gas escapes and checking possible external sources.

Verbatim wording from the response

“In relation to the GDN procedures, when the documents were reviewed as a whole and side by side, it was agreed that there was already a consistent approach to checking adjoining and adjacent properties when investigating an internal escape. However, detailed discussions continued in relation to whether the industry could clarify its existing procedures in this regard.”

Source location

Response from Cadent Gas, Northern Gas, Scotland Gas Wales and West Utilities
Page 1 · response
Published 8 February 2020

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

Provide local gas engineers with guidance on responding when attending affected properties.

Verbatim wording from the response

“2. Other properties in the immediate area at risk HSE, along with the Gas Safe Register, undertook extensive communication activity with both residents and gas engineers in the local area to advise them of the cause of the incident, the risk to their own properties and the action they could take to mitigate this. This included:”

Source location

Response from Health and Safety Executives
Page 2 · response
Published 8 February 2020

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

Engage affected residents through a local meeting and distributed leaflets explaining the property risk and mitigating actions.

Verbatim wording from the response

“2. Other properties in the immediate area at risk HSE, along with the Gas Safe Register, undertook extensive communication activity with both residents and gas engineers in the local area to advise them of the cause of the incident, the risk to their own properties and the action they could take to mitigate this. This included:”

Source location

Response from Health and Safety Executives
Page 2 · response
Published 8 February 2020

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

The HSE would separately consider action concerning the 254 properties at risk of floor failure.

Verbatim wording from the response

“This meeting was attended by the engineering policy leads for each of the GDNs, together with Steve Critchlow and Caroline Lane of the HSE. At this meeting, it was agreed that the GDNs did not have any power to take action in relation to the two hundred and fifty-four properties which were at risk of floors failing and the HSE would consider this point separately.”

Source location

Response from Cadent Gas, Northern Gas, Scotland Gas Wales and West Utilities
Page 1 · response
Published 8 February 2020

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

Existing GDN procedures already provided a consistent approach to checking adjoining and adjacent properties during internal gas-escape investigations.

Verbatim wording from the response

“In relation to the GDN procedures, when the documents were reviewed as a whole and side by side, it was agreed that there was already a consistent approach to checking adjoining and adjacent properties when investigating an internal escape. However, detailed discussions continued in relation to whether the industry could clarify its existing procedures in this regard.”

Source location

Response from Cadent Gas, Northern Gas, Scotland Gas Wales and West Utilities
Page 1 · response
Published 8 February 2020

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

The GDNs had no power to take action concerning the 254 properties at risk of floor failure.

Verbatim wording from the response

“This meeting was attended by the engineering policy leads for each of the GDNs, together with Steve Critchlow and Caroline Lane of the HSE. At this meeting, it was agreed that the GDNs did not have any power to take action in relation to the two hundred and fifty-four properties which were at risk of floors failing and the HSE would consider this point separately.”

Source location

Response from Cadent Gas, Northern Gas, Scotland Gas Wales and West Utilities
Page 1 · response
Published 8 February 2020

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.1

  1. 1

    Brief HSE and Gas Safe Register staff handling concerns from local residents or engineers.

    Stated by Health and Safety ExecutiveStated completedThe respondent said that this action was complete when they made their response on 8 February 2020.

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

Brief HSE and Gas Safe Register staff handling concerns from local residents or engineers.

Verbatim wording from the response

“2. Other properties in the immediate area at risk HSE, along with the Gas Safe Register, undertook extensive communication activity with both residents and gas engineers in the local area to advise them of the cause of the incident, the risk to their own properties and the action they could take to mitigate this. This included:”

Source location

Response from Health and Safety Executives
Page 2 · response
Published 8 February 2020

Open published response
Back to top

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

Official responses located
6/5

Data last updated 7 September 2026