PFD report

Samantha MacDonald · Prevention of Future Deaths report

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Issued 5 Feb 2016•Manchester West

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
13

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 keep bedroom window restrictors in good working order
    Part of recurring concern: Inadequate window fall-prevention controls in residential accommodation
  2. Failure of bedroom window restrictors to resist determined efforts to open windows
    Part of recurring concern: Inadequate window fall-prevention controls in residential accommodation
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

    Write to UUK and GuildHE by early July, urging higher education institutions to improve student accommodation safety and addressing risk assessments and robust window restrictors.

    Stated by Department for Business, Innovation & SkillsStated plannedThe respondent said that this action was planned when they made their response on 2 February 2016.
  2. Action

    Inspect window restrictors each student term and before new intake, repairing damage and notifying students of sanctions where necessary.

    Stated by Campus Living Villages UK LimitedStated completedThe respondent said that this action was complete when they made their response on 2 February 2016.
  3. Action

    Display warnings and develop separate safety procedures when work requires removal of window restrictors.

    Stated by Campus Living Villages UK LimitedStated completedThe respondent said that this action was complete when they made their response on 2 February 2016.

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

  1. Position

    Higher education institutions, rather than Government, are responsible for their own student-accommodation processes and procedures, including adherence to safety law.

    Stated by Department for Business, Innovation & SkillsRedirects 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

Failure to keep bedroom window restrictors in good working order

Wider context from the report

“Samantha Macdonald jumped from the window of her bedroom on the 14th floor of her student accommodation in Salford. The window was not required to be used as a fire exit because it was too high. The window was fitted with a device that restricted the distance for which it would open. Evidence was heard that the device complied with the relevant British Standard and Planning regulations. If it had been in good working order it would have prevented the window from opening sufficiently to allow Samantha’s exit. It was, however, broken. Evidence revealed that the device could be broken by the application of force without the use of any tool. It was not possible to discover exactly when the device had been broken although it had been working during Samantha’s tenancy. Similar devices fitted to other bedrooms in the building had been found to be broken from time to time. The building is a non-smoking building that is entirely devoted to student accommodation, and witnesses believed that the devices had probably been broken so that students smoking in their rooms could avoid detection. Evidence was heard that in accommodation occupied by adults who might be determined to forcibly defeat window restrictors, for example in a healthcare setting, risk assessments were recommended to be reviewed and consideration given to replacing restrictors with more substantial or robust devices, and /or adding a second restrictor to better resist determined efforts to open the window, thus lessening the risk of persons falling either accidentally or otherwise. It is considered that such assessments would also be appropriate in student accommodation such as that occupied by Samantha Macdonald. ”

Is this part of a recurring concern?

Yes — Inadequate window fall-prevention controls in residential accommodation.

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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 bedroom window restrictors to resist determined efforts to open windows

Wider context from the report

“Samantha Macdonald jumped from the window of her bedroom on the 14th floor of her student accommodation in Salford. The window was not required to be used as a fire exit because it was too high. The window was fitted with a device that restricted the distance for which it would open. Evidence was heard that the device complied with the relevant British Standard and Planning regulations. If it had been in good working order it would have prevented the window from opening sufficiently to allow Samantha’s exit. It was, however, broken. Evidence revealed that the device could be broken by the application of force without the use of any tool. It was not possible to discover exactly when the device had been broken although it had been working during Samantha’s tenancy. Similar devices fitted to other bedrooms in the building had been found to be broken from time to time. The building is a non-smoking building that is entirely devoted to student accommodation, and witnesses believed that the devices had probably been broken so that students smoking in their rooms could avoid detection. Evidence was heard that in accommodation occupied by adults who might be determined to forcibly defeat window restrictors, for example in a healthcare setting, risk assessments were recommended to be reviewed and consideration given to replacing restrictors with more substantial or robust devices, and /or adding a second restrictor to better resist determined efforts to open the window, thus lessening the risk of persons falling either accidentally or otherwise. It is considered that such assessments would also be appropriate in student accommodation such as that occupied by Samantha Macdonald. ”

Is this part of a recurring concern?

Yes — Inadequate window fall-prevention controls in residential accommodation.

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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

Write to UUK and GuildHE by early July, urging higher education institutions to improve student accommodation safety and addressing risk assessments and robust window restrictors.

Verbatim wording from the response

“However, my Department proposes to write to UUK, whose members consist of Vice-Chancellors, and GuildHE, a representative body for higher education providers, by early July, to ask them to ensure that HEIs are doing all they can to ensure the safety of students in such accommodation. In that letter we will also raise the points you have made concerning risk assessment and replacing window restrictors with more robust devices.”

Source location

2016-0036-Response-by-Department-fro-Business-Innovation-and-Skills
Page 2 · response
Published 2 February 2016

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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

Inspect window restrictors each student term and before new intake, repairing damage and notifying students of sanctions where necessary.

Verbatim wording from the response

“• Carried out checks of the latest each student term and prior to new student intake in September, including specific checks on window restrictors. Where window restrictors had been damaged or tampered with, CLV fixed the restrictors and issued a letter to the student concerned informing them of the potential for fines and/or disciplinary action should they break the window restrictor again.”

Source location

2016-0036-Response-by-Campus-Living-Villages
Page 2 · response
Published 2 February 2016

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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

Display warnings and develop separate safety procedures when work requires removal of window restrictors.

Verbatim wording from the response

“• When work is taking place at CLV properties which requires the removal of window restrictors, warning signs are put in place and separately safety procedures are developed.”

Source location

2016-0036-Response-by-Campus-Living-Villages
Page 2 · response
Published 2 February 2016

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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

Enforce a signed student rule prohibiting interference with or removal of window restrictors.

Verbatim wording from the response

“• Included a specific prohibition in ‘The Village Rules’, which students have to sign up to when renting a property. This states: “Window opening restrictor system is for your safety and must not be interfered with or removed. …Violation of this policy may, at the discretion of Village management, result in disciplinary action and a fine.””

Source location

2016-0036-Response-by-Campus-Living-Villages
Page 2 · response
Published 2 February 2016

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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 daily external checks for overcome window restrictors, taking action against students and reinstating restrictors when issues are identified.

Verbatim wording from the response

“In relation to risks associated with accidental falls, associated with broken or damaged restrictors, or those which are ineffective for any other reason (e.g. opened for window purposes), additional steps have now been put in place on top of those in place at the time of incident. These include:”

Source location

2016-0036-Response-by-Campus-Living-Villages
Page 2 · response
Published 2 February 2016

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

Higher education institutions, rather than Government, are responsible for their own student-accommodation processes and procedures, including adherence to safety law.

Verbatim wording from the response

“I should explain that Higher Education Institutions (“HEIs”) are independent and autonomous from Government, and are thus responsible for their own processes and procedures. In preparing this response, my officials have consulted with organisations in the higher education sector and other interested parties, but ultimately it is the responsibility of the HEIs themselves to adhere to the law.”

Source location

2016-0036-Response-by-Department-fro-Business-Innovation-and-Skills
Page 1 · response
Published 2 February 2016

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

Additional or more robust window restrictors are not considered the most effective or appropriate control for deliberate falls in a normal university setting.

Verbatim wording from the response

“We have considered the comments made in your Regulation 28 report about the potential use of secondary restrictors and/or more robust devices. As set out at the start of this report, we do not consider CLV to have the same risk profile or duties (and powers) of a healthcare organisation.”

Source location

2016-0036-Response-by-Campus-Living-Villages
Page 2 · response
Published 2 February 2016

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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 risk that force could break compliant window restrictors and cause accidental falls is considered eliminated and controlled by existing restrictors.

Verbatim wording from the response

“We have specifically considered the suggestion made at inquest that the application of force (rather than use of a tool) could result in window restrictors breaking. In the context of accidental falls, this has been considered and eliminated as a real risk and one that it is controlled through the use of restrictors complying with BS EN 14351.”

Source location

2016-0036-Response-by-Campus-Living-Villages
Page 2 · response
Published 2 February 2016

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.8

  1. 1

    Establish communication channels supporting staff and residents when mental-health concerns are identified.

    Stated by Campus Living Villages UK LimitedStated completedThe respondent said that this action was complete when they made their response on 2 February 2016.
  2. 2

    Conduct activity-specific risk assessments for higher-risk activities, including window cleaning and child-occupied holiday accommodation.

    Stated by Campus Living Villages UK LimitedStated completedThe respondent said that this action was complete when they made their response on 2 February 2016.
  3. 3

    Develop a Residential Life Programme with events, gatherings and campaigns to foster community and support resident mental health.

    Stated by Campus Living Villages UK LimitedStated completedThe respondent said that this action was complete when they made their response on 2 February 2016.
  4. 4

    Provide mental-health training to staff to help identify and support affected residents.

    Stated by Campus Living Villages UK LimitedStated completedThe respondent said that this action was complete when they made their response on 2 February 2016.
  5. 5

    Review risk assessments concerning falls from windows following the incident and inquest evidence.

    Stated by Campus Living Villages UK LimitedStated completedThe respondent said that this action was complete when they made their response on 2 February 2016.
  6. 6

    Develop a global mental-health campaign and model with specialist charities and universities to support students and reduce risks from deliberate falls.

    Stated by Campus Living Villages UK LimitedStated in progressThe respondent said that this action was in progress when they made their response on 2 February 2016.
  7. 7

    Introduce a crisis-management procedure for situations requiring it.

    Stated by Campus Living Villages UK LimitedStated completedThe respondent said that this action was complete when they made their response on 2 February 2016.
  8. 8

    Prepare separate risk assessments for accidental falls and deliberate acts causing falls through windows.

    Stated by Campus Living Villages UK LimitedStated completedThe respondent said that this action was complete when they made their response on 2 February 2016.

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

Establish communication channels supporting staff and residents when mental-health concerns are identified.

Verbatim wording from the response

“• Put in place key communication channels to support staff and affected residents in the event that an issue is identified which support;”

Source location

2016-0036-Response-by-Campus-Living-Villages
Page 3 · response
Published 2 February 2016

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 activity-specific risk assessments for higher-risk activities, including window cleaning and child-occupied holiday accommodation.

Verbatim wording from the response

“• Conducted specific risk assessments for specific activities which enhanced risk and set out control measures to address risk. These included risk assessments for window cleaning and for summer holiday rental of CLV flats when children would be present in the accommodation.”

Source location

2016-0036-Response-by-Campus-Living-Villages
Page 2 · response
Published 2 February 2016

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

Develop a Residential Life Programme with events, gatherings and campaigns to foster community and support resident mental health.

Verbatim wording from the response

“• Developed a Residential Life Programme which includes planned events, gatherings and promotional campaigns to bring residents together and foster a sense of community spirit, aimed at improving mental health and supporting those who could be suffering;”

Source location

2016-0036-Response-by-Campus-Living-Villages
Page 3 · response
Published 2 February 2016

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

Provide mental-health training to staff to help identify and support affected residents.

Verbatim wording from the response

“This project was agreed as a global priority for CLV in August 2015 and the commencement of the mental health initiative commenced in late 2015. This incident emphasised the importance of the project and CLV’s mental health model (which will still in its early stages) which has developed significantly since the incident. Specifically relevant to preventing a further incident similar to Samantha Macdonald’s, since the incident we have:”

Source location

2016-0036-Response-by-Campus-Living-Villages
Page 3 · response
Published 2 February 2016

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 risk assessments concerning falls from windows following the incident and inquest evidence.

Verbatim wording from the response

“We have considered evidence heard at inquest and, following incident, undertook a review of risk assessments relating to falls from windows.”

Source location

2016-0036-Response-by-Campus-Living-Villages
Page 2 · response
Published 2 February 2016

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

Develop a global mental-health campaign and model with specialist charities and universities to support students and reduce risks from deliberate falls.

Verbatim wording from the response

“deliberate act causing a fall through its windows is to focus on a mental health programme rather than the use of additional window restrictors.”

Source location

2016-0036-Response-by-Campus-Living-Villages
Page 3 · response
Published 2 February 2016

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 crisis-management procedure for situations requiring it.

Verbatim wording from the response

“• Introduced a crisis management procedure in the event that it is required.”

Source location

2016-0036-Response-by-Campus-Living-Villages
Page 3 · response
Published 2 February 2016

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 separate risk assessments for accidental falls and deliberate acts causing falls through windows.

Verbatim wording from the response

“New risk assessments specifically separating risks of an accidental fall from those linked to a deliberate act resulting in a fall were prepared and are enclosed with this response.”

Source location

2016-0036-Response-by-Campus-Living-Villages
Page 2 · response
Published 2 February 2016

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