PFD report

Brian George Harfield · Prevention of Future Deaths report

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Issued 16 Mar 2023•West Sussex

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. Lack of compulsory fire safety measures for extra care and retirement-type accommodation
    Part of recurring concern: Inadequate sprinkler protection in residential accommodation
  2. Failure of fire safety consultation scope to cover extra care facility risks
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.4

  1. Action

    Amend Approved Document B to reduce the height threshold for sprinkler provisions in blocks of flats, including applicable extra-care buildings.

    Stated by Ministry of Housing, Communities and Local GovernmentStated completedThe respondent said that this action was complete when they made their response on 22 March 2023.
  2. Action

    Conduct and commission phased research on sprinklers and other fire-protection measures in specialised housing.

    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 22 March 2023.
  3. Action

    Bring into force landlord requirements for smoke alarms on each storey and carbon monoxide alarms in rooms with fixed combustion appliances, including repair or replacement of faulty alarms.

    Stated by Ministry of Housing, Communities and Local GovernmentStated completedThe respondent said that this action was complete when they made their response on 22 March 2023.

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

  1. Position

    Insufficient evidence and definitions prevent extending sprinkler consultation requirements to extra care premises pending further research.

    Stated by Ministry of Housing, Communities and Local GovernmentUnable 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

Lack of compulsory fire safety measures for extra care and retirement-type accommodation

Wider context from the report

“The concerns relates to the fact that there is a lack of compulsory provision for sprinklers or other fire safety measures to protect those who live at home (outside of care homes) but are being provided with extra care facilities or those in retirement type provision. Due to there being an ageing population and a lack of care home spaces there is a growing number of people (who would normally be residing in care homes) who are now having to buy care packages to be delivered either in their own homes or other residential type of facilities. The providers of such accomodation are not subject to any fire safety provisions. People who find themselves in this type of facility do suffer declining health and mobility as time goes on. They are at a particular risk should a fire occur. They are more at risk than those in care homes as there is 24/7 staffing and trained individuals who are well versed in premises. In an extra care facility it is highly probable that should a fire start that the occupant would be unable to leave the room of fire origin/ flat of origin through ill health/ poor mobility, and who would be overcome by the toxic products of combustion prior to the Fire and Rescue service being alerted. This is exactly what happened in Mr Harfield’s case. We heard at this Inquest that whilst a sprinkler controlled fire would still produce smoke it would be of a lower level, and there is evidence that on the majority of occasions it does not just restrict the fires growth, but actually extinguishes it. It is understood that there is currently a Government consultation being undertaken on the subject of Sprinklers in Care homes but the scope of this consultation does not cover the specific risk to those in extra care facilities. This is a missed opportunity. The consultation can be found here. Sprinklers in care homes, removal of national classes, and staircases in residential buildings - GOV.UK (www.gov.uk) ”

Is this part of a recurring concern?

Yes — Inadequate sprinkler protection in residential accommodation.

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 of fire safety consultation scope to cover extra care facility risks

Wider context from the report

“The concerns relates to the fact that there is a lack of compulsory provision for sprinklers or other fire safety measures to protect those who live at home (outside of care homes) but are being provided with extra care facilities or those in retirement type provision. Due to there being an ageing population and a lack of care home spaces there is a growing number of people (who would normally be residing in care homes) who are now having to buy care packages to be delivered either in their own homes or other residential type of facilities. The providers of such accomodation are not subject to any fire safety provisions. People who find themselves in this type of facility do suffer declining health and mobility as time goes on. They are at a particular risk should a fire occur. They are more at risk than those in care homes as there is 24/7 staffing and trained individuals who are well versed in premises. In an extra care facility it is highly probable that should a fire start that the occupant would be unable to leave the room of fire origin/ flat of origin through ill health/ poor mobility, and who would be overcome by the toxic products of combustion prior to the Fire and Rescue service being alerted. This is exactly what happened in Mr Harfield’s case. We heard at this Inquest that whilst a sprinkler controlled fire would still produce smoke it would be of a lower level, and there is evidence that on the majority of occasions it does not just restrict the fires growth, but actually extinguishes it. It is understood that there is currently a Government consultation being undertaken on the subject of Sprinklers in Care homes but the scope of this consultation does not cover the specific risk to those in extra care facilities. This is a missed opportunity. The consultation can be found here. Sprinklers in care homes, removal of national classes, and staircases in residential buildings - GOV.UK (www.gov.uk) ”

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

Amend Approved Document B to reduce the height threshold for sprinkler provisions in blocks of flats, including applicable extra-care buildings.

Verbatim wording from the response

“My department and the new Building Safety Regulator keep guidance in Approved Document B including sprinkler provisions under close review. In 2020, the Government amended Approved Document B to reduce the height threshold (from 30 metres to 11 metres) for the inclusion of sprinklers in blocks of flats; this included extra care buildings designed as blocks of flats. The Building Safety Regulator now has a dedicated workstream to consider what additional fire safety measures may be necessary in specialised housing for vulnerable people, including in extra care facilities.”

Source location

Response from Department for Levelling Up, Housing and Communities
Page 2 · response
Published 22 March 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

Conduct and commission phased research on sprinklers and other fire-protection measures in specialised housing.

Verbatim wording from the response

“The Government recognises that further evidence is required on the benefit of sprinklers and other additional fire protection measures in specialised housing and, to this end, we have a dedicated research workstream in place. I will consider future research findings in light of your concerns and the evidence heard at Mr Harfield’s inquest, so that we can consider what changes are necessary to reduce the risk of similar incidents in the future. We have commissioned future research that will inform us of the benefit of sprinklers over other policy options such as enhancing fire detection and alarms or additional fire compartmentation. This will generate up-to-date evidence to help us review current building regulation policy and inform future changes.”

Source location

Response from Department for Levelling Up, Housing and Communities
Page 1 · response
Published 22 March 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

Bring into force landlord requirements for smoke alarms on each storey and carbon monoxide alarms in rooms with fixed combustion appliances, including repair or replacement of faulty alarms.

Verbatim wording from the response

“Residents in both new and existing extra care buildings have the right to expect safe, quality, healthy environments and there should be full consideration of the risks in a building to determine the right protection to keep residents safe. My department has taken steps to improve safety for people in privately and socially rented homes. The Smoke and Carbon Monoxide Alarm (Amendment) Regulations 2022 are now in force and, as of 1 October 2022, all private and social landlords must ensure: at least one smoke alarm is equipped on each storey of their homes where there is a room used as living accommodation; that a carbon monoxide alarm is equipped in any room used as living accommodation which contains a fixed combustion appliance (excluding gas cookers); and ensure smoke alarms and carbon monoxide alarms are repaired or replaced once informed and found that they are faulty.”

Source location

Response from Department for Levelling Up, Housing and Communities
Page 3 · response
Published 22 March 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

Consider research findings and determine what changes are necessary to reduce fire risks in specialised housing.

Verbatim wording from the response

“The Government recognises that further evidence is required on the benefit of sprinklers and other additional fire protection measures in specialised housing and, to this end, we have a dedicated research workstream in place. I will consider future research findings in light of your concerns and the evidence heard at Mr Harfield’s inquest, so that we can consider what changes are necessary to reduce the risk of similar incidents in the future. We have commissioned future research that will inform us of the benefit of sprinklers over other policy options such as enhancing fire detection and alarms or additional fire compartmentation. This will generate up-to-date evidence to help us review current building regulation policy and inform future changes.”

Source location

Response from Department for Levelling Up, Housing and Communities
Page 1 · response
Published 22 March 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

Insufficient evidence and definitions prevent extending sprinkler consultation requirements to extra care premises pending further research.

Verbatim wording from the response

“The Government recognises that further evidence is required on the benefit of sprinklers and other additional fire protection measures in specialised housing and, to this end, we have a dedicated research workstream in place. I will consider future research findings in light of your concerns and the evidence heard at Mr Harfield’s inquest, so that we can consider what changes are necessary to reduce the risk of similar incidents in the future. We have commissioned future research that will inform us of the benefit of sprinklers over other policy options such as enhancing fire detection and alarms or additional fire compartmentation. This will generate up-to-date evidence to help us review current building regulation policy and inform future changes.”

Source location

Response from Department for Levelling Up, Housing and Communities
Page 1 · response
Published 22 March 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

Existing buildings are governed by fire risk assessments requiring responsible persons to provide adequate and appropriate fire precautions.

Verbatim wording from the response

“Sprinklers in existing buildings Fire safety in existing buildings is covered by separate legislation which includes the Regulatory Reform (Fire Safety) Order 2005 (the FSO). The FSO, which is the responsibility of the Home Office, applies to the common parts of multi-occupied residential buildings and requires the responsible person (the person in control of the premises – usually the building owner, landlord or managing agent) to undertake and review regularly a fire risk assessment. The responsible person must then ensure that adequate and appropriate fire precautions that mitigate against the risk to life from fire are in place. It is for the responsible person to determine these measures, based on the fire risk assessment.”

Source location

Response from Department for Levelling Up, Housing and Communities
Page 2 · response
Published 22 March 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

Responsible persons, usually building owners, landlords or managing agents, must determine fire safety measures for existing buildings.

Verbatim wording from the response

“Sprinklers in existing buildings Fire safety in existing buildings is covered by separate legislation which includes the Regulatory Reform (Fire Safety) Order 2005 (the FSO). The FSO, which is the responsibility of the Home Office, applies to the common parts of multi-occupied residential buildings and requires the responsible person (the person in control of the premises – usually the building owner, landlord or managing agent) to undertake and review regularly a fire risk assessment. The responsible person must then ensure that adequate and appropriate fire precautions that mitigate against the risk to life from fire are in place. It is for the responsible person to determine these measures, based on the fire risk assessment.”

Source location

Response from Department for Levelling Up, Housing and Communities
Page 2 · response
Published 22 March 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.3

  1. 1

    Bring forward consultation proposals recommending sprinklers in all new care homes, regardless of height, to the current British Standard.

    Stated by Ministry of Housing, Communities and Local GovernmentStated completedThe respondent said that this action was complete when they made their response on 22 March 2023.
  2. 2

    Amend Approved Document J to require carbon monoxide alarms alongside fixed combustion appliances, excluding gas cookers.

    Stated by Ministry of Housing, Communities and Local GovernmentStated completedThe respondent said that this action was complete when they made their response on 22 March 2023.
  3. 3

    Introduce a more stringent building-safety regulatory regime led by the Building Safety Regulator.

    Stated by Ministry of Housing, Communities and Local GovernmentStated completedThe respondent said that this action was complete when they made their response on 22 March 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

Bring forward consultation proposals recommending sprinklers in all new care homes, regardless of height, to the current British Standard.

Verbatim wording from the response

“Our research work is being phased; stage 1 has already found a body of existing evidence for sprinklers in care homes that enabled us to bring forward evidence-based policy proposals for sprinklers ahead of completion of the research workstream.”

Source location

Response from Department for Levelling Up, Housing and Communities
Page 1 · response
Published 22 March 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

Amend Approved Document J to require carbon monoxide alarms alongside fixed combustion appliances, excluding gas cookers.

Verbatim wording from the response

“You will also want to know that the Government amended the statutory guidance (Approved Document J) supporting Part J of the Building Regulations to require that carbon monoxide alarms are fitted alongside the installation of fixed combustion appliances of any fuel type (excluding gas cookers). Fire safety guidance for tenants and landlords and can be found on gov.uk: https://www.gov.uk/government/publications/fire-safety-of-your-building-advice-for-tenants-and-residents/fire-safety-of-your-building-for-tenants-and-residents”

Source location

Response from Department for Levelling Up, Housing and Communities
Page 3 · response
Published 22 March 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 building-safety regulatory regime led by the Building Safety Regulator.

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 the performance of all buildings to ensure the safety of occupants. I have forwarded your letter to Philip White who has taken up the role of Director of Building Safety at the Building Safety Regulator, pending recruitment of the next Chief Inspector of Buildings.”

Source location

Response from Department for Levelling Up, Housing and Communities
Page 3 · response
Published 22 March 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