PFD report

Kenneth Arthur Brincombe · Prevention of Future Deaths report

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Issued 25 Aug 2017•Plymouth, Torbay and South Devon

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
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
10

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 raised4

  1. Inability of a person with the relevant disability to take evasive action during a fire
  2. Failure to recognise that carers were not obliged to facilitate smoking despite the fire risk
    Part of recurring concern: Inadequate management of smoking-related fire risks in vulnerable people
  3. Lack of carer training to assess household and appliance fire hazards
    Part of recurring concern: Failure to ensure staff competence in fire safety and evacuation
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.9

  1. Action

    Inform NHS and DCC staff using the community equipment service about incident learning and available assistive-technology alerting solutions.

    Stated by Devon County CouncilStated plannedThe respondent said that this action was planned when they made their response on 25 August 2018.
  2. Action

    Raise incident learning and alternative alerting options through local and countywide management forums.

    Stated by Devon County CouncilStated plannedThe respondent said that this action was planned when they made their response on 25 August 2018.
  3. Action

    Share incident learning and alerting options with the Provider Engagement Network, including reminders about robust risk assessment and escalation of concerns.

    Stated by Devon County CouncilStated plannedThe respondent said that this action was planned when they made their response on 25 August 2018.

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

  1. Position

    The provider should determine measures for carers facilitating dangerous activities under its internal policies, practices and CQC requirements.

    Stated by Devon County CouncilRedirects 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

Inability of a person with the relevant disability to take evasive action during a fire

Wider context from the report

“(3) Mr Brincombe had received advice and had three smoke detectors fitted, however these would only alert Mr Brincombe to the fire. The smoke detectors would not alert a fire station, and in Mr Brincombe’s level of disability he would be unable to take evasive action. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 to recognise that carers were not obliged to facilitate smoking despite the fire risk

Wider context from the report

“(1) There was an assumption that because Mr Brincombe wanted to smoke that the carers had no choice but to facilitate this despite putting Mr Brincombe and his neighbours at risk of death by fire. ”

Is this part of a recurring concern?

Yes — Inadequate management of smoking-related fire risks in vulnerable people.

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 carer training to assess household and appliance fire hazards

Wider context from the report

“(2) In evidence the carer confirmed that the carers were responsible for maintaining a safe environment, but had no training in how to assess whether the house and the appliances were safe or whether they posed a fire hazard. ”

Is this part of a recurring concern?

Yes — Failure to ensure staff competence in fire safety and evacuation.

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 smoke detectors to alert a fire station

Wider context from the report

“(3) Mr Brincombe had received advice and had three smoke detectors fitted, however these would only alert Mr Brincombe to the fire. The smoke detectors would not alert a fire station, and in Mr Brincombe’s level of disability he would be unable to take evasive action. ”

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 respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Inform NHS and DCC staff using the community equipment service about incident learning and available assistive-technology alerting solutions.

Verbatim wording from the response

“b) The new NHS and DCC community equipment service contract has assistive technology solutions available for alerting in these situations. We will ensure that all 2000 plus NHS and DCC staff who access this service are informed of the learning from this incident and directed to the solutions available within the service. Community equipment service Prescriber Newsletter and Newsflash to be issued by April 2018.”

Source location

Kenneth-BRINICOMBE-Response
Page 4 · response
Published 25 August 2018

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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

Raise incident learning and alternative alerting options through local and countywide management forums.

Verbatim wording from the response

“c) Learning from this incident to be raised via local and countywide management fora, to include reminders regarding options for alerting. By end April 2018”

Source location

Kenneth-BRINICOMBE-Response
Page 4 · response
Published 25 August 2018

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

Share incident learning and alerting options with the Provider Engagement Network, including reminders about robust risk assessment and escalation of concerns.

Verbatim wording from the response

“d) Learning from the incident, options and solutions will be shared with the Provider Engagement Network (for independent service providers) to include a reminder for the need to undertake robust risk assessments and alert the relevant social care team should ongoing concerns arise. By end April 2018”

Source location

Kenneth-BRINICOMBE-Response
Page 4 · response
Published 25 August 2018

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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

Use Care Act assessments, risk-based analysis and care planning to identify and address fire risks through support or assistive technology.

Verbatim wording from the response

“6. The care management processes and documentation that support the assessment and support responsibilities under the Care Act, include risk based analysis against the Care Act eligibility outcomes as set out in Regulation 2(2) of the Care and Support (Eligibility Criteria) Regulations 2014:”

Source location

Kenneth-BRINICOMBE-Response
Page 2 · response
Published 25 August 2018

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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

Inform DCC care management staff about incident learning and remind them to consider alternative alerting options in similar circumstances.

Verbatim wording from the response

“a) All DCC care management staff to be informed of the learning from this incident and reminded of the need to consider alternative alerting options in any similar circumstances. Next monthly DCC staff newsletter due mid April 2018.”

Source location

Kenneth-BRINICOMBE-Response
Page 4 · response
Published 25 August 2018

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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

Provide carers with induction health and safety training covering risk assessment, hazardous substances and fire safety.

Verbatim wording from the response

“All of our carers receive health and safety training during induction. This includes:”

Source location

Kenneth-BRINICOMBE-Response2
Page 1 · response
Published 25 August 2018

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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

Invite the fire brigade’s Community Safety Champion to brief carers between formal training cycles on available support and fire risks.

Verbatim wording from the response

“This training is refreshed every 3 years. In between this training we invite the Community Safety Champion in from the fire brigade, where they give a talk to the carers about what the fire service can do to help and support, when to contact them and what risks to look for.”

Source location

Kenneth-BRINICOMBE-Response2
Page 2 · response
Published 25 August 2018

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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

Refresh carers’ health and safety training every three years.

Verbatim wording from the response

“All of our carers receive health and safety training during induction. This includes:”

Source location

Kenneth-BRINICOMBE-Response2
Page 1 · response
Published 25 August 2018

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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 comprehensive customer, environmental and activity-specific risk assessments, with six-monthly or change-triggered reviews, led by trained senior care workers.

Verbatim wording from the response

“For all customers that we provide a service for we undertake a number of risk assessments. This includes a full assessment of the customer and their care needs and an environmental risk assessment that looks at the customers surroundings. We then carry out further risk assessments dependent on the two standard assessments already undertaken. In this case, and because the customer did choose to smoke, we carried out a risk assessment around that activity.”

Source location

Kenneth-BRINICOMBE-Response2
Page 1 · response
Published 25 August 2018

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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 provider should determine measures for carers facilitating dangerous activities under its internal policies, practices and CQC requirements.

Verbatim wording from the response

“Describe what measures should be taken when carers are being asked to facilitate an activity which will endanger the lives of the individual concerned and others.”

Source location

Kenneth-BRINICOMBE-Response
Page 3 · response
Published 25 August 2018

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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 Fire Service does not have facilities to monitor individual properties or respond directly to smoke-detector alerts.

Verbatim wording from the response

“Confirm whether in future, where a vulnerable adult is at high risk of accidental starting a fire, putting himself and others lives in danger, and being unable to take any action if this occurs, that smoke detectors would be fitted that have a direct link to a fire station.”

Source location

Kenneth-BRINICOMBE-Response
Page 3 · response
Published 25 August 2018

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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 most suitable fire-risk technology must be agreed with social services, the individual and other relevant parties.

Verbatim wording from the response

“3. Confirm whether in future, where a vulnerable adult is at high risk of accidental starting a fire, putting himself and others lives in danger, and being unable to take any action if this occurs, that smoke detectors would be fitted that have a direct link to a fire station.”

Source location

Kenneth-BRINICOMBE-Response2
Page 2 · response
Published 25 August 2018

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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

    Provide mandatory induction and annual update training covering Care Act responsibilities, care management processes and fire-related risks.

    Stated by Devon County CouncilStated completedThe respondent said that this action was complete when they made their response on 25 August 2018.

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 mandatory induction and annual update training covering Care Act responsibilities, care management processes and fire-related risks.

Verbatim wording from the response

“5. All Local authority staff who are involved in the assessment and provision of services to support vulnerable individuals, receive comprehensive induction and mandatory yearly update training regarding responsibilities under the Care Act and the care management processes resulting from those responsibilities. The risks for the individual, including those relating to fire, form a routine part of these training courses and are routinely discussed by staff and trainers as part of these sessions.”

Source location

Kenneth-BRINICOMBE-Response
Page 2 · response
Published 25 August 2018

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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