PFD report

Ruth Ann PINGREE · Prevention of Future Deaths report

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Issued 8 Apr 2025•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.

View original report
Concerns
10

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
3

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 raised10

  1. Lack of clear standards for achieving required fire-safety standards
    Part of recurring concern: Inadequate clarity of fire-safety standards and guidance
  2. Lack of clear standards for required fire-safety measures
    Part of recurring concern: Inadequate clarity of fire-safety standards and guidance
  3. Ad hoc fire-safety assurance and enforcement
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

    Enhance the legal status of fire safety guidance under Section 156 of the Building Safety Act.

    Stated by Ministry of Housing, Communities and Local GovernmentStated completedThe respondent said that this action was complete when they made their response on 15 April 2025.
  2. Action

    Publish updated fire safety guidance for small paying guest accommodation, including caravans and recommended fire precautions.

    Stated by Ministry of Housing, Communities and Local GovernmentStated completedThe respondent said that this action was complete when they made their response on 15 April 2025.
  3. Action

    Require fire risk assessments to be recorded with all findings, rather than only significant findings.

    Stated by Ministry of Housing, Communities and Local GovernmentStated completedThe respondent said that this action was complete when they made their response on 15 April 2025.

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 clear standards for achieving required fire-safety standards

Wider context from the report

“The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO). In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO. This does not require that the proprietors: . keep any written records; . set a specific interval of maintenance inspections; or . provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency. There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted. Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take. The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc. This is in the context of businesses providing accommodation to the public on a paid basis. There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this. ”

Is this part of a recurring concern?

Yes — Inadequate clarity of fire-safety standards and guidance.

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 clear standards for required fire-safety measures

Wider context from the report

“The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO). In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO. This does not require that the proprietors: . keep any written records; . set a specific interval of maintenance inspections; or . provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency. There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted. Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take. The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc. This is in the context of businesses providing accommodation to the public on a paid basis. There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this. ”

Is this part of a recurring concern?

Yes — Inadequate clarity of fire-safety standards and guidance.

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

Ad hoc fire-safety assurance and enforcement

Wider context from the report

“The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO). In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO. This does not require that the proprietors: . keep any written records; . set a specific interval of maintenance inspections; or . provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency. There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted. Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take. The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc. This is in the context of businesses providing accommodation to the public on a paid basis. There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 defined guidance, format, scope and frequency for fire-safety risk assessments

Wider context from the report

“The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO). In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO. This does not require that the proprietors: . keep any written records; . set a specific interval of maintenance inspections; or . provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency. There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted. Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take. The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc. This is in the context of businesses providing accommodation to the public on a paid basis. There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this. ”

Is this part of a recurring concern?

Yes — Inadequate fire risk assessments.

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 required written fire-safety records

Wider context from the report

“The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO). In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO. This does not require that the proprietors: . keep any written records; . set a specific interval of maintenance inspections; or . provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency. There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted. Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take. The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc. This is in the context of businesses providing accommodation to the public on a paid basis. There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Reliance on individual research ability to interpret fire-safety requirements

Wider context from the report

“The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO). In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO. This does not require that the proprietors: . keep any written records; . set a specific interval of maintenance inspections; or . provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency. There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted. Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take. The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc. This is in the context of businesses providing accommodation to the public on a paid basis. There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this. ”

Is this part of a recurring concern?

Yes — Inadequate clarity of fire-safety standards and guidance.

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 clear standards for assessing applicable fire-safety measures

Wider context from the report

“The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO). In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO. This does not require that the proprietors: . keep any written records; . set a specific interval of maintenance inspections; or . provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency. There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted. Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take. The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc. This is in the context of businesses providing accommodation to the public on a paid basis. There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this. ”

Is this part of a recurring concern?

Yes — Inadequate clarity of fire-safety standards and guidance.

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 required caravan fire-safety signage and emergency notices

Wider context from the report

“The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO). In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO. This does not require that the proprietors: . keep any written records; . set a specific interval of maintenance inspections; or . provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency. There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted. Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take. The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc. This is in the context of businesses providing accommodation to the public on a paid basis. There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Failure to establish relevant fire-safety guidance as minimum standards

Wider context from the report

“The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO). In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO. This does not require that the proprietors: . keep any written records; . set a specific interval of maintenance inspections; or . provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency. There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted. Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take. The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc. This is in the context of businesses providing accommodation to the public on a paid basis. There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this. ”

Is this part of a recurring concern?

Yes — Inadequate clarity of fire-safety standards and guidance.

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 specified intervals for maintenance inspections

Wider context from the report

“The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO). In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO. This does not require that the proprietors: . keep any written records; . set a specific interval of maintenance inspections; or . provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency. There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted. Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take. The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc. This is in the context of businesses providing accommodation to the public on a paid basis. There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Enhance the legal status of fire safety guidance under Section 156 of the Building Safety Act.

Verbatim wording from the response

“Since the tragic death of Mrs Pingree, the Government has enhanced the status of guidance issued under Article 50 through Section 156 of the Building Safety Act, which now means that in any proceedings on a breach of the FSO, the court can consider whether failure to comply with guidance tends to establish if there was a contravention (with the converse point that compliance with guidance may be relied upon to establish there was no contravention).”

Source location

Response from Ministry of Housing, Communities and Local Government
Page 1 · response
Published 15 April 2025

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

Publish updated fire safety guidance for small paying guest accommodation, including caravans and recommended fire precautions.

Verbatim wording from the response

“The Government published an update to this guide titled “Making your small paying guest accommodation safe from fire” which superseded the older paying guests guide in March 2023 and is available as a free download on GOV.UK. The new guide tends to be more stringent in relation to the fire precautions it recommends.”

Source location

Response from Ministry of Housing, Communities and Local Government
Page 2 · response
Published 15 April 2025

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

Require fire risk assessments to be recorded with all findings, rather than only significant findings.

Verbatim wording from the response

“Since the fire, the Government has also changed the requirements on fire risk assessments where they all now need to be recorded, and it is no longer limited to just ‘significant’ findings but all findings.”

Source location

Response from Ministry of Housing, Communities and Local Government
Page 2 · response
Published 15 April 2025

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

Official responses located
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Data last updated 7 September 2026