Frazer Lee George Livesey · Prevention of Future Deaths report

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Issued 21 Nov 2016•Cumbria

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an 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
10

Described in responses

Recipients and published responses

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. Failure of window stays to be disableable from inside in an emergency
    Part of recurring concern: Unsafe emergency egress arrangements

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.10

  1. Impact Housing

    Assess other general-needs properties through stock-condition, repair and maintenance processes and include restrictor changes in the rolling inspection programme.

  2. Impact Housing

    Remind staff to periodically reinforce evacuation procedures with tenants according to their circumstances.

  3. Impact Housing

    Complete a full review of fire precaution and evacuation arrangements.

  4. Impact Housing

    Specify emergency-overridable or absent window restrictors and emergency-exitable window designs in new and replacement housing, subject to building constraints.

  5. Impact Housing

    Increase reminders to younger residents and other tenants about risks from forbidden activities and appliances.

  6. Impact Housing

    Adapt or replace existing non-overridable window restrictors in schemes where windows are not being replaced.

  7. Impact Housing

    Introduce procedures to reduce risks arising when building use, tenant circumstances or building components change.

  8. Impact Housing

    Remove the cable restrictors from the Old Fire Station flat’s windows.

  9. Impact Housing

    Conduct a further high-level review of higher-risk properties with the two lead consultants.

  10. Impact Housing

    Survey staff-supported residential properties and phase removal or replacement of fixed restrictors with emergency-overridable restrictors according to risk, phasing and funding.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Impact Housing

    Existing fire safety arrangements and procedures worked as designed, including containment and the designated exit route.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. Impact Housing

    The incident resulted from a unique, unusual rapid flashover that residential properties could not reasonably be foreseen or designed to protect against.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  3. Impact Housing

    Window exit will remain restricted for upper-floor tenants with dementia or impaired judgement because jumping risks are too great.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  4. Impact Housing

    Window changes cannot be applied universally because of safety risks, building design, regulatory restrictions, tenant vulnerability and potentially prohibitive replacement costs.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
  5. Impact Housing

    Nothing further could reasonably have been done within existing good practice to foresee and prevent the incident.

    No action considered necessaryThe respondent said that no further action was needed.

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 window stays to be disableable from inside in an emergency

Wider context from the report

“The concern is that the window stays could not be disabled from the inside in an emergency, it is possible the deceased could have survived and his friend suffered less serious injuries if they had been able to escape. ”

Is this part of a recurring concern?

Yes — Unsafe emergency egress arrangements.

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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

Assess other general-needs properties through stock-condition, repair and maintenance processes and include restrictor changes in the rolling inspection programme.

Verbatim wording from the response

“All other general needs properties. 2,300 properties | To be assessed through general stock condition surveys, repairs or maintenance. As properties become vacant, i.e. [“Properties as they become void”] they will be treated as for “Refurbished or remodelled properties “above. We have a 5yr rolling programme of inspection of all properties and we will include the removal or replacement of restrictors in those properties as they come up for inspection.”

Source location

2016-0418-Response-by-IMPACT
Page 8 · response
Published 19 February 2017

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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

Remind staff to periodically reinforce evacuation procedures with tenants according to their circumstances.

Verbatim wording from the response

“4. Whilst the fire evacuation arrangements worked as planned, we will reiterate to all of our staff the need to periodically remind our tenants of the procedures in place for their specific circumstances”

Source location

2016-0418-Response-by-IMPACT
Page 5 · response
Published 19 February 2017

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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

Complete a full review of fire precaution and evacuation arrangements.

Verbatim wording from the response

“We note the matters of concern raised in the Coroners Regulation 28 Letter. We have carried out a full review of our approach to fire precaution and evacuation. This response has been prepared in conjunction with ████████ of Total Fire Services Ltd and Rowena Jackson, independent Health and Safety Consultant¹. It is broken down into 3 key sections:”

Source location

2016-0418-Response-by-IMPACT
Page 1 · response
Published 19 February 2017

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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

Specify emergency-overridable or absent window restrictors and emergency-exitable window designs in new and replacement housing, subject to building constraints.

Verbatim wording from the response

“New Development Properties | Controls | Action Newbuild schemes that have not yet reached Building | Building Regulation approval is in all cases required for the works, and therefore the windows installed would have to comply and be approved by Building Control (and also on new build the third party warranty provided, such as LABC, Premier Guarantee etc) also up to relatively recently the most schemes would be Govt funded and have to meet the “Housing Quality Standards”. All of these requirements put differing constraints on the exact nature of any windows and opening mechanisms. | Windows installed in schemes from now on (see definition) will normally be UPVC outward opening side hung casement window, with easy clean hinges (to enable the window to be cleaned from the inside) with lockable handle and a restrictor which can be easily overridden in an emergency.”

Source location

2016-0418-Response-by-IMPACT
Page 6 · response
Published 19 February 2017

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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 reminders to younger residents and other tenants about risks from forbidden activities and appliances.

Verbatim wording from the response

“1. Our Tenancy and Licence Agreements cover such forbidden activities. We will ensure that younger residents in particular are more regularly reminded of the risks of carrying out forbidden activities in our buildings, with further explanation as to why these are forbidden activities”

Source location

2016-0418-Response-by-IMPACT
Page 5 · response
Published 19 February 2017

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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

Adapt or replace existing non-overridable window restrictors in schemes where windows are not being replaced.

Verbatim wording from the response

“From now on, in such schemes, where we are not replacing windows, existing windows with restrictors without an override will be adapted or replaced to achieve as near as possible the approach set out above”

Source location

2016-0418-Response-by-IMPACT
Page 7 · response
Published 19 February 2017

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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 procedures to reduce risks arising when building use, tenant circumstances or building components change.

Verbatim wording from the response

“3. We have a number of slightly different housing and support arrangements, for which we have slightly differing procedures (eg. fully supported schemes, low support schemes, newly designed schemes, schemes where there is a change of use, properties where there is a change of tenant). Whilst there is nothing that we will do significantly differently in the Old Fire Station (other than works to the windows; see below), there is a potential weakness where a situation changes- in particular where the use of the building changes (say, a more vulnerable tenant) and where we are considering changing a building component (say, replacing an existing window). We will bring in new procedures to ensure that any new risks introduced as a result of these changes of circumstance are reduced so far as is reasonably practicable”

Source location

2016-0418-Response-by-IMPACT
Page 5 · response
Published 19 February 2017

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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

Remove the cable restrictors from the Old Fire Station flat’s windows.

Verbatim wording from the response

“In this particular flat (Old Fire Station, ground floor), our proposal is as follows:”

Source location

2016-0418-Response-by-IMPACT
Page 6 · response
Published 19 February 2017

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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

Conduct a further high-level review of higher-risk properties with the two lead consultants.

Verbatim wording from the response

“5. With our 2 lead consultants, we will carry out a further, high level, review of our higher risk properties to see if there is any further learning”

Source location

2016-0418-Response-by-IMPACT
Page 5 · response
Published 19 February 2017

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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

Survey staff-supported residential properties and phase removal or replacement of fixed restrictors with emergency-overridable restrictors according to risk, phasing and funding.

Verbatim wording from the response

“Existing Properties Properties | Action Residential properties with staff on site. Vulnerable tenants, different building | All properties to be surveyed by end March 2017 to identify styles of windows and window”

Source location

2016-0418-Response-by-IMPACT
Page 7 · response
Published 19 February 2017

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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

Existing fire safety arrangements and procedures worked as designed, including containment and the designated exit route.

Verbatim wording from the response

“1. The fire safety arrangements and procedures in place worked as they were designed²”

Source location

2016-0418-Response-by-IMPACT
Page 4 · response
Published 19 February 2017

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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 incident resulted from a unique, unusual rapid flashover that residential properties could not reasonably be foreseen or designed to protect against.

Verbatim wording from the response

“3. The incident and sequence of events were of a unique and unusual nature (the consequences of a rapid flash over from ignited petrol vapours) that residential properties cannot reasonably be foreseen and designed to protect against”

Source location

2016-0418-Response-by-IMPACT
Page 4 · response
Published 19 February 2017

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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

Window exit will remain restricted for upper-floor tenants with dementia or impaired judgement because jumping risks are too great.

Verbatim wording from the response

“2. We will continue to restrict ease of window exit for all properties with tenants in upper floor flats with dementia or otherwise impaired judgement, where the risk to them of trying to jump from a window would be too great”

Source location

2016-0418-Response-by-IMPACT
Page 8 · response
Published 19 February 2017

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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

Window changes cannot be applied universally because of safety risks, building design, regulatory restrictions, tenant vulnerability and potentially prohibitive replacement costs.

Verbatim wording from the response

“2. Not all properties can have their restrictors removed (eg on upper floors where the risk from a fall would be high or where Building Regulations do not allow it)”

Source location

2016-0418-Response-by-IMPACT
Page 6 · response
Published 19 February 2017

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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

Nothing further could reasonably have been done within existing good practice to foresee and prevent the incident.

Verbatim wording from the response

“2. There was nothing further that a reasonable landlord could be expected within existing good practice to have done to foresee and prevent”

Source location

2016-0418-Response-by-IMPACT
Page 4 · response
Published 19 February 2017

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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