PFD report

Trevor John Ridd · Prevention of Future Deaths report

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Issued 16 Jun 2026•Birmingham and Solihull

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
7

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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.

Report evidence summary

Concerns raised7

  1. Lack of regular testing and maintenance of the sprinkler system
    Part of recurring concern: Inadequate sprinkler protection in residential accommodation
  2. Failure to ensure operators distinguish fault and fire notifications and escalate appropriately
    Part of recurring concern: Failure of fire detection systems to reliably alert and trigger emergency response
  3. Failure to provide operators with relevant property risk information alerts
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.7

  1. Action

    Continue reviewing training requirements and operator competency arrangements through continuous improvement and TSA accreditation processes.

    Stated by Birmingham City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.
  2. Action

    Review training and operator competency arrangements, embedding learning on alarm distinctions, individual assessment and escalation through procedures, briefings and supervision.

    Stated by Birmingham City CouncilStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
  3. Action

    Add mandatory electronic pop-up reminders requiring operators to acknowledge review of notifications before continuing call handling.

    Stated by Birmingham City CouncilStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The sprinkler notification transmitter was correctly configured and wired, so the signals were not sent in the wrong order because of installation error.

    Stated by Birmingham City CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 regular testing and maintenance of the sprinkler system

Wider context from the report

“3. It is not clear what training or instruction individual operators receive in relation to how they are to deal with situations where two notification signals are received in quick succession. It is also unclear what information alerts (if any) are communicated to individual operators in respect of the property from which the signals are received i.e. was it noted that the signals came from Mr Ridd’s property who was bed-bound and a known smoker with severe COPD where there had been a previous incident where he had singed his blanket from smoking in his bed? 4. The evidence at Inquest suggested that the two signals received were the wrong way around however it was not clear why this was and whether this has since been rectified. 5. There is no evidence of regular testing and maintenance of the sprinkler system. 6. It is not clear what individual operators have been ‘briefed’ on post-incident with regards to situations where two notification signals are received in quick succession from the same property. ”

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 to ensure operators distinguish fault and fire notifications and escalate appropriately

Wider context from the report

“2. It remains unclear as to why the individual operator treated both signals as being part of the same incident and failed to raise a 999 call; it is not clear how a fault notification works alongside a fire notification. ”

Is this part of a recurring concern?

Yes — Failure of fire detection systems to reliably alert and trigger emergency response.

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 provide operators with relevant property risk information alerts

Wider context from the report

“3. It is not clear what training or instruction individual operators receive in relation to how they are to deal with situations where two notification signals are received in quick succession. It is also unclear what information alerts (if any) are communicated to individual operators in respect of the property from which the signals are received i.e. was it noted that the signals came from Mr Ridd’s property who was bed-bound and a known smoker with severe COPD where there had been a previous incident where he had singed his blanket from smoking in his bed? 4. The evidence at Inquest suggested that the two signals received were the wrong way around however it was not clear why this was and whether this has since been rectified. 5. There is no evidence of regular testing and maintenance of the sprinkler system. 6. It is not clear what individual operators have been ‘briefed’ on post-incident with regards to situations where two notification signals are received in quick succession from the same property. ”

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 provide staff with a clear process for verifying secondary signal wording

Wider context from the report

“7. It is not clear what communications have been issued to staff to reinforce the requirement to verify wording of any secondary signals, nor is it clear how staff are to verify the wording of secondary signals. ”

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 a clear procedure for handling fault and fire signals received in quick succession

Wider context from the report

“1. It is not clear why the sprinkler system generated two signals (one ‘fault’ and one ‘fire’) within seconds of one another and what the procedure was for handling this. ”

Is this part of a recurring concern?

Yes — Failure of fire detection systems to reliably alert and trigger emergency response.

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 ensure correct ordering of sprinkler fault and fire signals

Wider context from the report

“3. It is not clear what training or instruction individual operators receive in relation to how they are to deal with situations where two notification signals are received in quick succession. It is also unclear what information alerts (if any) are communicated to individual operators in respect of the property from which the signals are received i.e. was it noted that the signals came from Mr Ridd’s property who was bed-bound and a known smoker with severe COPD where there had been a previous incident where he had singed his blanket from smoking in his bed? 4. The evidence at Inquest suggested that the two signals received were the wrong way around however it was not clear why this was and whether this has since been rectified. 5. There is no evidence of regular testing and maintenance of the sprinkler system. 6. It is not clear what individual operators have been ‘briefed’ on post-incident with regards to situations where two notification signals are received in quick succession from the same property. ”

Is this part of a recurring concern?

Yes — Failure of fire detection systems to reliably alert and trigger emergency response.

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 training and briefing for operators on handling notification signals received in quick succession

Wider context from the report

“3. It is not clear what training or instruction individual operators receive in relation to how they are to deal with situations where two notification signals are received in quick succession. It is also unclear what information alerts (if any) are communicated to individual operators in respect of the property from which the signals are received i.e. was it noted that the signals came from Mr Ridd’s property who was bed-bound and a known smoker with severe COPD where there had been a previous incident where he had singed his blanket from smoking in his bed? 4. The evidence at Inquest suggested that the two signals received were the wrong way around however it was not clear why this was and whether this has since been rectified. 5. There is no evidence of regular testing and maintenance of the sprinkler system. 6. It is not clear what individual operators have been ‘briefed’ on post-incident with regards to situations where two notification signals are received in quick succession from the same property. ”

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

Continue reviewing training requirements and operator competency arrangements through continuous improvement and TSA accreditation processes.

Verbatim wording from the response

“3. Training requirements and operator competency arrangements will continue to be reviewed as part of the service's continuous improvement framework and TSA accreditation requirements.”

Source location

Response from Birmingham City County
Page 7 · response
Published 14 August 2026

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 training and operator competency arrangements, embedding learning on alarm distinctions, individual assessment and escalation through procedures, briefings and supervision.

Verbatim wording from the response

“In addition to the procedural changes outlined above, the organisation recognises that effective operator training is fundamental to the safe operation of the Alarm Receiving Centre. Training requirements and operator competency arrangements have therefore been reviewed following this incident to ensure staff clearly understand the distinction between different alarm types, the need to assess each notification and the requirement to follow escalation procedures regardless of whether another notification from the same property is already being managed. This learning has been embedded through written procedures, management briefings, individual supervision and staff acknowledgement processes.”

Source location

Response from Birmingham City County
Page 6 · response
Published 14 August 2026

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

Add mandatory electronic pop-up reminders requiring operators to acknowledge review of notifications before continuing call handling.

Verbatim wording from the response

“• Electronic Pop-Up notifications created in the system as a reminder on every call to review all notifications even if they are received in close succession from the same property. Each ‘Pop-Up’ has to be acknowledged & closed by operators before they can continue to handle that or any further calls.”

Source location

Response from Birmingham City County
Page 4 · response
Published 14 August 2026

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

Update procedures so duplicate or successive notifications are individually acknowledged, assessed, actioned and escalated.

Verbatim wording from the response

“Following the incident, all procedures relating to the management of duplicate notifications and multiple alerts from the same site have been reviewed and updated. The revised procedures now make explicit that each notification must be individually acknowledged, assessed, actioned and closed, regardless of whether another notification has already been received from the same property.”

Source location

Response from Birmingham City County
Page 3 · response
Published 14 August 2026

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

Obtain written confirmation from all operators that they have read, understood and will comply with revised procedures.

Verbatim wording from the response

“• Written confirmation is being obtained from all operators to confirm they have read, understood and will comply with the revised procedures. This assurance exercise will be completed by the end of August 2026.”

Source location

Response from Birmingham City County
Page 4 · response
Published 14 August 2026

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

Issue written instructions and deliver verbal briefings reinforcing separate assessment of each notification and verification of its wording and classification.

Verbatim wording from the response

“Immediately following the incident, management issued written instructions to all operators reinforcing that duplicate notifications from the same site must not be assumed to relate to an existing incident and that each notification must be reviewed and actioned separately. This requirement was further reinforced through verbal briefings at the commencement of shifts and more recently through individual recorded discussions with all call handling operators.”

Source location

Response from Birmingham City County
Page 4 · response
Published 14 August 2026

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

Continue individual operator discussions through supervision to reinforce learning and maintain compliance with revised procedures.

Verbatim wording from the response

“• Further individual discussions have subsequently been undertaken and are ongoing and being formally recorded with each operator.”

Source location

Response from Birmingham City County
Page 4 · response
Published 14 August 2026

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

The sprinkler notification transmitter was correctly configured and wired, so the signals were not sent in the wrong order because of installation error.

Verbatim wording from the response

“Post-incident investigations undertaken by servicing and maintenance contractors identified that the CHUBB Skyresponse platform transmitter had been correctly configured and wired correctly. There was not an error in installation configuration sending notifications the incorrect way around.”

Source location

Response from Birmingham City County
Page 5 · response
Published 14 August 2026

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

The sprinkler system is subject to annual servicing and maintenance in accordance with the applicable British Standard.

Verbatim wording from the response

“The sprinkler system at Hobbis House is subject to annual servicing and maintenance in accordance with BS 9251:2021, the British Standard Code of Practice for fire sprinkler systems in domestic and residential occupancies.”

Source location

Response from Birmingham City County
Page 5 · response
Published 14 August 2026

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.1

  1. 1

    Continue annual TSA quality assurance and accreditation audits of procedures, training arrangements and operational compliance.

    Stated by Birmingham City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.

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

Continue annual TSA quality assurance and accreditation audits of procedures, training arrangements and operational compliance.

Verbatim wording from the response

“The Careline Alarm Receiving Centre is independently audited annually by the Technology Enabled Care Services Association (TSA) as part of its quality assurance and accreditation requirements. As part of the post-incident & annual review, procedures and operator guidance have been reviewed to strengthen compliance and ensure greater clarity in relation to the management of multiple notifications received from the same property.”

Source location

Response from Birmingham City County
Page 6 · response
Published 14 August 2026

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