PFD report

Sylvia Frances PRICE · Prevention of Future Deaths report

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Issued 4 Jan 2022•Suffolk

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
5

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. Lack of an enforceable requirement for appropriate signage identifying accessible toilet facilities in public access buildings
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

    Prepare and publish a technical consultation on changes to toilet-provision Building Regulations and Approved Documents, informed by evidence and public views.

    Stated by Ministry of Housing, Communities and Local GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.
  2. Action

    Review Approved Document M coherently with the new statutory toilet-provision guidance.

    Stated by Ministry of Housing, Communities and Local GovernmentStated plannedThe respondent said that this action was planned when they made their response on 9 January 2023.
  3. Action

    Prepare new statutory guidance on non-residential toilet provision, giving appropriate prominence to signage for Building Control Officers.

    Stated by Ministry of Housing, Communities and Local GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.

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

  1. Position

    Local authorities are responsible for enforcing health and safety requirements, including signage-related risk controls, in premises within their areas.

    Stated by Ministry of Housing, Communities and Local GovernmentRedirects 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

Lack of an enforceable requirement for appropriate signage identifying accessible toilet facilities in public access buildings

Wider context from the report

“Evidence was heard that Sylvia had underlying medical issues that required an easily accessible toilet facility. The jury concluded that the lack of appropriate signage, to readily identify an easily accessible toilet facility, was a directly contributory factor leading to Sylvia’s death. The Local Authority Food and Safety Officer who investigated this case identified no other contributing factors, with the stairs themselves meeting building and safety regulations. The officers report contained only one recommendation for the premises owner, which was the provision of more adequate signage. However, the officer stated in evidence that there was no statutory power to enforce the provision of such signage, and should a premises owner wish to ignore such a recommendation, they could (it is acknowledged that the premise owner in this case has put new signage in place). In addition, current building regulations do not require any such signage to be fitted into new buildings. The court was informed that the provision of accessible toilet facilities is now a legal requirement for the majority of buildings designed for public use, but as detailed above there is no requirement for these facilities to be clearly identified with appropriate signage. As a failure to provide adequate signage was found to be a contributing factor in this case, and there is no enforceable requirement that such signage should be provided, I am concerned further deaths may occur in other public access buildings, should similar circumstances arise in the future. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Prepare and publish a technical consultation on changes to toilet-provision Building Regulations and Approved Documents, informed by evidence and public views.

Verbatim wording from the response

“You set out matters of concern and recommended that I, in my capacity as the Secretary of State, should take action to prevent future deaths. In this letter, I set out the work currently underway by officials in my department and at the Building Safety Regulator to update Building Regulations regarding toilet provision and to prepare statutory guidance in a new Approved Document. There will be a period of public consultation to supplement evidence already held by the department. I can assure you that I will consider findings that arise and what changes are necessary to reduce the risk of similar incidents in the future.”

Source location

Response from Department for Levelling Up, Housing & Communities
Page 1 · response
Published 9 January 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

Review Approved Document M coherently with the new statutory toilet-provision guidance.

Verbatim wording from the response

“Technical changes to Building Regulations and Approved Documents The Government’s call for evidence on toilet provision for men and women ended in February 2021. Following that, in July last year, the Government set out its intention to launch a technical consultation on formal changes to the Building Regulations and Approved Documents. We are preparing the consultation document now with a view to publication later this summer. We will seek views on the design and range of toilet provision, so that we can prepare new statutory guidance. We will draw on evidence from commissioned research to inform possible design suggestions for a variety of non-residential toilet facilities including wheelchair-accessible toilets, toilet signage and labelling. I will ensure that a review of Approved Document M is coherent with the new statutory guidance we will prepare on toilet provision.”

Source location

Response from Department for Levelling Up, Housing & Communities
Page 2 · response
Published 9 January 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

Prepare new statutory guidance on non-residential toilet provision, giving appropriate prominence to signage for Building Control Officers.

Verbatim wording from the response

“You set out matters of concern and recommended that I, in my capacity as the Secretary of State, should take action to prevent future deaths. In this letter, I set out the work currently underway by officials in my department and at the Building Safety Regulator to update Building Regulations regarding toilet provision and to prepare statutory guidance in a new Approved Document. There will be a period of public consultation to supplement evidence already held by the department. I can assure you that I will consider findings that arise and what changes are necessary to reduce the risk of similar incidents in the future.”

Source location

Response from Department for Levelling Up, Housing & Communities
Page 1 · response
Published 9 January 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

Local authorities are responsible for enforcing health and safety requirements, including signage-related risk controls, in premises within their areas.

Verbatim wording from the response

“Health and safety legislation and enforcement In workplaces (including hotels), a need for signage to mitigate risks (based on principles of prevention) would normally be identified as part of routine management risk assessment procedures; the relevant legislation is the Health and Safety at Work Act 1974, the Health and Safety (Enforcing Authority) Regulations 1998, and the Management of Health and Safety at Work Regulations 1999. Health and safety legislation requires every employer to make a suitable and sufficient assessment of the risks to the health and safety of employees and persons who are not in the employer’s employment but where risks might arise out of or in connection with their business. Local authorities are responsible for enforcement relating to premises in their area.”

Source location

Response from Department for Levelling Up, Housing & Communities
Page 3 · response
Published 9 January 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

Building Regulations cannot require unmodified existing buildings to be altered, limiting action on signage in those premises.

Verbatim wording from the response

“Approved Document M (‘Access to and use of buildings – Volume 2: Buildings other than dwellings’) is the relevant statutory guidance in such a case. It sets out design considerations for toilet accommodation (including wheelchair accessible toilets) at paragraphs 5.5 to 5.10 and includes guidance on other provisions, e.g. support rails and a wash basin. Additionally, building design professionals are directed to BS8300 which covers provision of signs and information. The Building Regulations apply to new design and construction; they are not retrospective. A Building Control Body (including local authority Building Control Officers and Approved Inspectors) will make sure that building regulations are followed in new buildings or when building works (as defined in the Building Regulations 2010) are carried out.”

Source location

Response from Department for Levelling Up, Housing & Communities
Page 2 · response
Published 9 January 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

Service providers must make reasonable adjustments, potentially including accessible toilet signage, for disabled customers using existing premises.

Verbatim wording from the response

“Equality Act 2010: reasonable adjustments to existing premises The Equality Act 2010 provides protections for people with disabilities who may encounter difficulties in accessing existing premises. Service providers are under an anticipatory duty to make reasonable adjustments to enable customers with disabilities to use their premises and facilities. An obligation to make reasonable adjustments is continuous. The Equality and Human Rights Commission notes that if a disabled person wants to use an organisation’s services but encounters barriers, then the organisation needs to think about reasonable adjustments whether or not any adjustments have already been made. In premises open to the public, this may involve making changes where barriers have been created by the physical features of those premises, or providing auxiliary aids or auxiliary services.”

Source location

Response from Department for Levelling Up, Housing & Communities
Page 3 · response
Published 9 January 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.2

  1. 1

    Consider consultation findings and determine necessary changes to reduce the risk of similar incidents.

    Stated by Ministry of Housing, Communities and Local GovernmentStated plannedThe respondent said that this action was planned when they made their response on 9 January 2023.
  2. 2

    Introduce a more stringent regulatory regime led by the Building Safety Regulator to oversee building safety and identify regulatory failures.

    Stated by Ministry of Housing, Communities and Local GovernmentStated completedThe respondent said that this action was complete when they made their response on 9 January 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

Consider consultation findings and determine necessary changes to reduce the risk of similar incidents.

Verbatim wording from the response

“You set out matters of concern and recommended that I, in my capacity as the Secretary of State, should take action to prevent future deaths. In this letter, I set out the work currently underway by officials in my department and at the Building Safety Regulator to update Building Regulations regarding toilet provision and to prepare statutory guidance in a new Approved Document. There will be a period of public consultation to supplement evidence already held by the department. I can assure you that I will consider findings that arise and what changes are necessary to reduce the risk of similar incidents in the future.”

Source location

Response from Department for Levelling Up, Housing & Communities
Page 1 · response
Published 9 January 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 a more stringent regulatory regime led by the Building Safety Regulator to oversee building safety and identify regulatory failures.

Verbatim wording from the response

“Building Safety Regulator Finally, we have introduced a more stringent regulatory regime led by the Building Safety Regulator. The Building Safety Regulator has responsibilities for overseeing the safety of all buildings, including identifying patterns of regulatory failure and making recommendations for improving standards. This will drive continuous improvement in buildings technology and construction techniques. I have sent your report to ████████ who has taken up the role of Director of Building Safety at the Building Safety Regulator.”

Source location

Response from Department for Levelling Up, Housing & Communities
Page 3 · response
Published 9 January 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