PFD report

Sylvia Pollitt · Prevention of Future Deaths report

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Issued 19 Jul 2023•Manchester South

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

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 raised2

  1. Failure to capture and monitor referral outcomes
    Part of recurring concern: Failure of case monitoring to identify cases requiring follow-up
  2. Lack of an audit system for non-escalation following referrals
    Part of recurring concern: Failure to act appropriately on safeguarding referrals and notices
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

    Hold weekly contractor meetings, reconcile work-in-progress reports with internal records, and review every repair to prevent unauthorised abortion without escalation.

    Stated by London & Quadrant Housing TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
  2. Action

    Automatically follow up incomplete or requested-aborted repairs and escalate unsuccessful resident contact for an in-person welfare check.

    Stated by London & Quadrant Housing TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
  3. Action

    Review all gas repairs closed outside the agreed service level without reference back, tracing records and identifying closure reasons.

    Stated by London & Quadrant Housing TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.

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

Failure to capture and monitor referral outcomes

Wider context from the report

“The inquest heard evidence that under the SLA between the Housing Association and Liberty if there is non-contact following a referral then this should be escalated back to the Housing Association so that they can carry out welfare checks and assess the position further. Carrying out of welfare checks for vulnerable adults ensures that they are safe and well. That did not happen in Mrs Pollitt’s case. The evidence before the inquest was that the Housing Association had: 1. No audit system which enabled it to know if this issue of non-escalation by Liberty was a one off or a frequent issue. They had only become aware of the non-contact in this instance following Sylvia Pollitt’s death. 2. No system where they captured/monitored the outcome of each referral to their subcontractor e.g. non-contact; successful attendance. ”

Is this part of a recurring concern?

Yes — Failure of case monitoring to identify cases requiring follow-up.

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

Lack of an audit system for non-escalation following referrals

Wider context from the report

“The inquest heard evidence that under the SLA between the Housing Association and Liberty if there is non-contact following a referral then this should be escalated back to the Housing Association so that they can carry out welfare checks and assess the position further. Carrying out of welfare checks for vulnerable adults ensures that they are safe and well. That did not happen in Mrs Pollitt’s case. The evidence before the inquest was that the Housing Association had: 1. No audit system which enabled it to know if this issue of non-escalation by Liberty was a one off or a frequent issue. They had only become aware of the non-contact in this instance following Sylvia Pollitt’s death. 2. No system where they captured/monitored the outcome of each referral to their subcontractor e.g. non-contact; successful attendance. ”

Is this part of a recurring concern?

Yes — Failure to act appropriately on safeguarding referrals and notices.

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

Hold weekly contractor meetings, reconcile work-in-progress reports with internal records, and review every repair to prevent unauthorised abortion without escalation.

Verbatim wording from the response

“That notwithstanding, we have subsequently instituted weekly meetings with Liberty to review every single job raised to trace all those in progress, overdue, completed and requested to be aborted. A full Work In Progress (WIP) report is produced by Liberty which is reconciled against the list held by L&Q and is reviewed by the Gas Compliance Manager weekly to ensure every single repair is accounted for. No jobs are permitted or are possible to be aborted directly by Liberty without reference back to L&Q and the report records all reasons for no access and dates of escalation back to L&Q.”

Source location

Response from L&Q
Page 3 · response
Published 21 July 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

Automatically follow up incomplete or requested-aborted repairs and escalate unsuccessful resident contact for an in-person welfare check.

Verbatim wording from the response

“All cases of incomplete and requested aborted jobs are automatically followed up by the L&Q gas team to make contact with the resident and if this is unsuccessful, they are immediately passed to the housing management team to make an in-person welfare check.”

Source location

Response from L&Q
Page 3 · response
Published 21 July 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

Review all gas repairs closed outside the agreed service level without reference back, tracing records and identifying closure reasons.

Verbatim wording from the response

“As soon as we were aware of the incident and the inquest, we immediately reviewed every other gas repair request which had been closed by Liberty outside of the agreed SLA and without reference back to L&Q.”

Source location

Response from L&Q
Page 2 · response
Published 21 July 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

Record relevant calls centrally and track every repair through the internal housing management system to maintain an auditable trail.

Verbatim wording from the response

“Following the inquest and prior to your formal recommendations contained within this Regulation 28 Prevention of Future Deaths report, we had immediately put in place additional processes and checks. This included aligning the process of the former THT with that of L&Q where all calls of this nature are recorded by and within the central call centre prior to being passed to contractors, ensuring that a comprehensive record of all repairs is tracked and managed through our internal housing management system. The previous THT process was to transfer the resident call directly to the contractor, in this incident Liberty.”

Source location

Response from L&Q
Page 2 · response
Published 21 July 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

Align property services and building compliance policies and processes, including gas safety and contractor management.

Verbatim wording from the response

“To provide some context, we would like to highlight that Mrs Pollitt’s death occurred during a transition phase for L&Q and the previous Trafford Housing Trust (“THT”), this was as the two entities were integrating, a process which completed on 31st March 2023. The processes in place at the time were those of THT. This is not intended to avoid any ownership of the incident on our part, it is to provide the context. We have since aligned the L&Q property services and building compliance policies and processes, which includes the gas safety and contractor management processes. This shall, as we will hopefully demonstrate, now provide greater control and will prevent future deaths from these incidents occurring.”

Source location

Response from L&Q
Page 2 · response
Published 21 July 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

    Review the contractual arrangements with the contractor.

    Stated by London & Quadrant Housing TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 July 2023.
  2. 2

    Self-refer to the Social Housing Regulator to formally track mitigating actions.

    Stated by London & Quadrant Housing TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 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

Review the contractual arrangements with the contractor.

Verbatim wording from the response

“With respect to the ongoing relationship with Liberty, their contractual arrangements are currently under review.”

Source location

Response from L&Q
Page 3 · response
Published 21 July 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

Self-refer to the Social Housing Regulator to formally track mitigating actions.

Verbatim wording from the response

“We also confirm that we also took immediate action following the inquest and prior to the report in self-referring ourselves to the Regulator for Social Housing in order to formally track our mitigating actions.”

Source location

Response from L&Q
Page 1 · response
Published 21 July 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