PFD report

Jane BENNETT · Prevention of Future Deaths report

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Issued 24 Nov 2024•Nottinghamshire

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
23

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 raised1

  1. Mould in residential properties
    Part of recurring concern: Inadequate control of damp and mould hazards in residential 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.22

  1. Action

    Maintain referral links with health, social care and education services, including fast-track pathways for damp and mould issues.

    Stated by Mansfield District CouncilStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
  2. Action

    Trial environmental monitoring devices in tenants’ homes to support damp, mould and condensation cases.

    Stated by Mansfield District CouncilStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2023.
  3. Action

    Disseminate tenant guidance on identifying damp and mould and reducing internal moisture through packs, inspections, publications and online information.

    Stated by Mansfield District CouncilStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.

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

  1. Position

    Completing the remaining mould inspections depends on tenants allowing access to their homes.

    Stated by Mansfield District CouncilUnable 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

Mould in residential properties

Wider context from the report

“I am concerned that mould in Mrs. Bennett’s property and other properties in that area owned and maintained by Mansfield District Council may pose a risk that future deaths could occur. I ask for the aforesaid properties to be inspected for mould and action be taken to ensure any further exposure to mould by any tenant is minimised. ”

Is this part of a recurring concern?

Yes — Inadequate control of damp and mould hazards in residential properties.

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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 referral links with health, social care and education services, including fast-track pathways for damp and mould issues.

Verbatim wording from the response

“• Proactive working and established links with health, public health and social care (including safeguarding teams) and education providers to support identification and resolution of damp, condensation and mould growth factors found in tenant’s homes, and encouraging instances to be reported for prompt action. The undertook a ‘Preventing Family Homeless’ pilot with Children’s”

Source location

Response from Mansfield District Council
Page 8 · response
Published 8 December 2023

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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

Trial environmental monitoring devices in tenants’ homes to support damp, mould and condensation cases.

Verbatim wording from the response

“• Trialling environmental monitoring devices for placement in tenant’s homes to assist with supporting tenants that report damp, mould or condensation.”

Source location

Response from Mansfield District Council
Page 10 · response
Published 8 December 2023

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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

Disseminate tenant guidance on identifying damp and mould and reducing internal moisture through packs, inspections, publications and online information.

Verbatim wording from the response

“• We co-produced guidance information and support for tenants to help identify instances of damp, mould and condensation and help to reduce high levels of internal moisture in properties.”

Source location

Response from Mansfield District Council
Page 8 · response
Published 8 December 2023

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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

Increase contractor capacity to support prioritised and timely damp repairs and mould treatments.

Verbatim wording from the response

“• Increase the capacity of contractors, both local and framework contractors, to support with damp works and mould treatments to ensure a prioritised and timely response to damp and mould treatment.”

Source location

Response from Mansfield District Council
Page 10 · response
Published 8 December 2023

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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 website with damp, mould and condensation guidance, including moisture-reduction advice.

Verbatim wording from the response

“• Updated our website to provide further guidance on damp, mould and condensation including tips to reduce moisture in the home.”

Source location

Response from Mansfield District Council
Page 9 · response
Published 8 December 2023

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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

Develop a pilot with health partners to train social prescribers in housing-related damp and mould matters.

Verbatim wording from the response

“• The council is currently developing a pilot project in Mansfield with Mid-Notts Place Based Partnership and health partners to train social prescribers in housing matters, including damp and mould growth, with specific emphasis on families with children experiencing respiratory conditions.”

Source location

Response from Mansfield District Council
Page 9 · response
Published 8 December 2023

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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

Continue the social-media campaign providing damp, mould and condensation advice.

Verbatim wording from the response

“• Ongoing damp and mould social media campaign that has been running on council social media accounts since November 2023. In total the campaign has reached 85,778 people on Facebook and a further 3,815 on X (formerly Twitter).”

Source location

Response from Mansfield District Council
Page 8 · response
Published 8 December 2023

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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

Increase inspection-team capacity for investigating reported damp, mould and condensation.

Verbatim wording from the response

“• Increased the capacity of the inspection team responsible for visiting homes and investigating reports of damp, mould and condensation.”

Source location

Response from Mansfield District Council
Page 10 · response
Published 8 December 2023

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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

Treat mould identified during neighbouring-home inspections within repairs target timescales.

Verbatim wording from the response

“Of the homes inspected, mould growth has been identified in 15 homes and in all cases, mould growth has been minimal. In all cases where mould has been identified however, mould treatment will be completed in agreement with the tenant within the council’s repairs target timescales. Mould treatment works have started on site by a specialist mould treatment company. All 64 tenants have received detailed advice to support them to minimise moisture levels and reduce the risk of mould in the future. A second reminder letter will be sent week beginning 22 January 23 to those tenants that have not yet contacted the council with the aim of completing all remaining inspections by 16 February 23. This programme is dependent upon tenants allowing access.”

Source location

Response from Mansfield District Council
Page 3 · response
Published 8 December 2023

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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

Provide the Healthy Homes Hub to support vulnerable residents with property-condition risks, including damp, mould and condensation.

Verbatim wording from the response

“• Provision of a Mansfield ‘Healthy Homes Hub’ (See Appendix 6) to support the most vulnerable tenants and residents to stay safe in their home. Support with property condition, including damp, mould and condensation, is included within the hub model.”

Source location

Response from Mansfield District Council
Page 9 · response
Published 8 December 2023

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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

Participate in social-housing decarbonisation and domestic retrofit projects to improve council-home thermal efficiency.

Verbatim wording from the response

“The council has also taken part in the social housing decarbonisation demonstrator project as well as a domestic retrofit project within the D2N2 devolution programme with a view to improving the thermal efficiency of council homes.”

Source location

Response from Mansfield District Council
Page 7 · response
Published 8 December 2023

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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

Introduce an interim procedure addressing potential Awaab’s Law repair timescales and actions.

Verbatim wording from the response

“• Introduced an interim procedure that considers the potential timescales and actions suggested in the consultation document - Awaab’s Law: Consultation on timescales for repairs in the social rented sector.”

Source location

Response from Mansfield District Council
Page 9 · response
Published 8 December 2023

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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 trained operatives and specialist contractors to treat reported mould, investigate root causes and arrange follow-on repairs or technical inspections.

Verbatim wording from the response

“• Early, proactive action. Inspectors identify the root cause of damp and mould at the earliest opportunity with the support of a range of trained operatives attending to treat any mould with escalation to qualified professionals as required. All operatives have received both Housing Health and Safety Rating (HHSRS) training appropriate to their roles as well as damp and mould training. Training to utilise dampness measurement equipment has also been completed.”

Source location

Response from Mansfield District Council
Page 7 · response
Published 8 December 2023

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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

Hold frequent contractor performance meetings to monitor damp and mould treatment progress and prioritisation.

Verbatim wording from the response

“• Ongoing frequent performance management meetings with contractors dealing with damp and mould treatment to monitor progress and ensure properties are prioritised where there are occupants that could be significantly affected by damp and mould due to medical conditions.”

Source location

Response from Mansfield District Council
Page 9 · response
Published 8 December 2023

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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

Commission an independent consultant to review the council’s approach to damp and mould.

Verbatim wording from the response

“• The council have commissioned an independent consultant from Savills to review the council’s approach to damp and mould.”

Source location

Response from Mansfield District Council
Page 9 · response
Published 8 December 2023

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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

Increase capital investment in housing components and improvement programmes addressing root causes of damp and mould.

Verbatim wording from the response

“This data has helped shape the direction and investment profile of our homes over the short, medium and longer term. This work combined has resulted in a significant increase in sustainable capital investment in council homes as part of the medium term financial strategy. Increased financial resource and capacity in this area also contributes to the council’s approach to addressing the root causes of damp and mould via windows, doors, roofing, heating and electrical upgrade programmes.”

Source location

Response from Mansfield District Council
Page 7 · response
Published 8 December 2023

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

Train relevant colleagues and contractors to identify, report and resolve damp, mould and condensation risks.

Verbatim wording from the response

“• Early, proactive action. Inspectors identify the root cause of damp and mould at the earliest opportunity with the support of a range of trained operatives attending to treat any mould with escalation to qualified professionals as required. All operatives have received both Housing Health and Safety Rating (HHSRS) training appropriate to their roles as well as damp and mould training. Training to utilise dampness measurement equipment has also been completed.”

Source location

Response from Mansfield District Council
Page 7 · response
Published 8 December 2023

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

Introduce scripted triage prompts for all tenant-reported damp, mould and condensation cases.

Verbatim wording from the response

“• Introduced a triage system with scripted prompts for all reported damp, mould and condensation cases reported by the tenant.”

Source location

Response from Mansfield District Council
Page 9 · response
Published 8 December 2023

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 the ASSIST Hospital Discharge service for housing-related support, including damp, mould and condensation matters.

Verbatim wording from the response

“• Provision of an ASSIST Hospital Discharge service in partnership with Sherwood Forest Hospital Trust and the Integrated Care System (See Appendix 7) to support discharge cases requiring housing-related support (which can include property conditions such as damp, mould and condensation matters) and prevent admission through work in the community.”

Source location

Response from Mansfield District Council
Page 9 · response
Published 8 December 2023

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

Procure specialist mould-treatment kits for appropriate tenant use.

Verbatim wording from the response

“• Procured mould kits from specialist mould treatment company for tenant usage to support tenants to prevent mould growth where appropriate.”

Source location

Response from Mansfield District Council
Page 10 · response
Published 8 December 2023

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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

Inspect identified neighbouring council homes for mould and provide tenants with tailored moisture-reduction advice.

Verbatim wording from the response

“In response to the request for the council to inspect properties in that area for mould, the council wrote to tenants accordingly. Appendix 4 details the letter dated 14 December 2023 sent by first class post by the council to council tenants living on Eather Avenue, Slant Lane and certain homes on Park Road advising that the”

Source location

Response from Mansfield District Council
Page 2 · response
Published 8 December 2023

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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

Work with external contractors to identify early warning signs of damp and mould and respond proactively.

Verbatim wording from the response

“• Working with external contractors to ensure early warning ‘on the ground’ of damp and mould growth in properties enabling us to proactively respond and prevent any further property damage and tenant risk.”

Source location

Response from Mansfield District Council
Page 9 · response
Published 8 December 2023

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

Completing the remaining mould inspections depends on tenants allowing access to their homes.

Verbatim wording from the response

“Of the homes inspected, mould growth has been identified in 15 homes and in all cases, mould growth has been minimal. In all cases where mould has been identified however, mould treatment will be completed in agreement with the tenant within the council’s repairs target timescales. Mould treatment works have started on site by a specialist mould treatment company. All 64 tenants have received detailed advice to support them to minimise moisture levels and reduce the risk of mould in the future. A second reminder letter will be sent week beginning 22 January 23 to those tenants that have not yet contacted the council with the aim of completing all remaining inspections by 16 February 23. This programme is dependent upon tenants allowing access.”

Source location

Response from Mansfield District Council
Page 3 · response
Published 8 December 2023

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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 medical report did not establish whether mould contributed to the interstitial lung disease, and identified other possible causes.

Verbatim wording from the response

“The report concludes the cause of Mrs Bennett’s Interstitial Lung Disease (ILD) remains unclear. Blood tests which might support exposure to fungus were negative. Causes of ILD remained unclear and inconclusive. Possible causes included vaping, the medications Mrs Bennett was taking as well as possible mould (based on the photos the consultants were shown by Mrs Bennett). The report does not distinguish between these three factors. ████████ advises he did not see the mould himself and therefore it is difficult for him to give an opinion on the balance of probabilities whether it did in fact contribute.”

Source location

Response from Mansfield District Council
Page 4 · response
Published 8 December 2023

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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

Mould was found only inside bedroom furniture, not on walls or elsewhere in the home, limiting the stated extent of the mould risk.

Verbatim wording from the response

“With reference to the Sherwood Forest Hospital (SFH) statement of Dr Hutchinson, Consultant in Respiratory Medicine (Appendix 3), on 5th June 2023 a consultant advises they were shown photos of mould on the walls of Mrs Bennett’s home. These photos have not been included within the SFH report and therefore the council are unable to comment on this. However, the photos provided by Mrs Bennett dated the 3rd and 4th of January 2023 (Appendix 2) that have been provided to the council by the Coroner appear to show mould on Mrs Bennett’s drawers and wardrobe only and not on any walls.”

Source location

Response from Mansfield District Council
Page 4 · response
Published 8 December 2023

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

    Deliver a councillor workshop on damp, mould and condensation advice and signposting.

    Stated by Mansfield District CouncilStated plannedThe respondent said that this action was planned when they made their response on 8 December 2023.

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

Deliver a councillor workshop on damp, mould and condensation advice and signposting.

Verbatim wording from the response

“• Planned councillor workshop focussing on damp, mould and condensation to assist members to provide advice and signposting to constituents.”

Source location

Response from Mansfield District Council
Page 10 · response
Published 8 December 2023

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