Fire risk assessment failures
Systemic failures in fire safety, including inadequate risk assessments and unaddressed actions, posing risks to residents.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
87match
#18 - Limited qualified professionals compromise quality and consistency of PAS 9980 fire risk assessments.
The National Fire Chiefs Council (NFCC) told us that the PAS 9980 standard for assessing the fire safety risk of external walls relied on specialist knowledge of building construction, fire engineering principles and material performance. The NFCC warned that there was limited availability of qualified professionals, and that its members were concerned that current PAS 9980 assessments were...
Matched on
terms: assessment, fire
PFD report
81match
Sean Ennis
Inadequate fire risk assessments and an unregulated telecare sector fail to ensure vulnerable residents receive essential safety provisions and monitoring, exacerbated by a lack of person-centred risk assessments and accreditation.
Matched on
terms: assessment, fire
PFD report
77match
Robert Spring
Inadequate communication channels failed to inform the Fire and Rescue Service about high-risk home oxygen users who smoked, preventing assessment for crucial safety equipment like smoke alarms and flame-retardant bedding.
Matched on
terms: assessment, fire
PFD report
77match
Bernard Hender
Whirlpool's risk assessments for appliance fires were inadequate, with a dismissive approach to field data like reported fires. This prevents timely learning and proactive measures to enhance product safety and save lives.
Matched on
terms: assessment, fire
PFD report
77match
Pauline Oakley
There was no safety assessment of the patient's flat or appliances upon hospital discharge. Additionally, the fire alarm system was unmonitored, relying on residents who may have assumed it was.
Matched on
terms: assessment, fire
Committee recommendation
74match
#34 - Inconsistent PAS 9980 fire risk appraisals lead to significant delays and disputes.
Under the PAS 9980 methodology, competent professionals conduct Fire Risk Appraisals of External Walls (FRAEWs) in which they make conclusions about the risk to life posed by a building’s cladding and make proposals about remedial measures to reduce the level of risk to ‘tolerable’,57 The National Fire Chiefs Council (NFCC) told us that the PAS 9980 assessments were...
Matched on
terms: assessment, fire
PFD report
73match
Robert Wood
Fire risk assessment guidelines did not prioritise pre-alteration reviews, and Junior Fire NCOs lacked specific training on complex electrical overload risks, including high current draw appliances.
Matched on
terms: assessment, fire
PFD report
73match
Ian Morley
A patient's deteriorating condition failed to trigger a necessary fresh risk assessment, compounded by inadequate fire risk management at the care facility.
Matched on
terms: assessment, fire
PFD report
73match
Pauline Taylor
Emollient creams with paraffin pose an unrecognised fire hazard due to inadequate warnings and lack of awareness, alongside insufficient patient risk assessments.
Matched on
terms: assessment, fire
PFD report
73match
Matthew Hatfield
Soldiers lacked clarity on gun safety drills, and the officer in charge lacked critical information on tank status. Risk assessments also failed to identify a design flaw allowing guns to fire without a vital safety assembly.
Matched on
terms: assessment, fire
PFD report
73match
Ashleigh Timms
Fire safety failures included incompetent staff, non-compliant fire alarms without automatic emergency service links, unfit policies, flawed audits, and dangerous keypad locks on exit doors.
Matched on
terms: failure, fire
HMICFRS recommendation
73match
FRS 2021-22 CoC Recommendations: London Fire Brigade
Cause of concern: The brigade doesn’t adequately prioritise HFSVs on the basis of risk. It doesn’t have a system in place that allows for the consistent assessment of risk levels among those people it has already identified as being at greatest risk from fire. Recommendation: By 31 May 2022, the brigade should develop an action plan to:- develop...
Matched on
terms: assessment, fire
Inquiry recommendation
70match
P2-10 - Require fire safety strategy from registered fire engineer at Gateway 2
That it be made a statutory requirement that a fire safety strategy produced by a registered fire engineer to be submitted with building control applications (at Gateway 2) for the construction or refurbishment of any higher-risk building and for it to be reviewed and re-submitted at the stage of completion (Gateway 3). Such a strategy must take into...
Matched on
terms: fire
Inquiry recommendation
70match
P1-5 - Require building floor plans for fire services
The owner and manager of every high-rise residential building be required by law to provide their local fire and rescue services with up-to-date plans in both paper and electronic form of every floor of the building identifying the location of key fire safety systems.
Matched on
terms: fire
Committee recommendation
70match
#13 - Government funding programmes exclude non-cladding fire safety defects, burdening property owners and leaseholders.
In their written evidence to us, the National Fire Chiefs Council (NFCC) and The Property Institute also raised concerns about the exclusion of non– cladding defects from government funded programmes. The NFCC told us there was a “large proportion” of buildings needing temporary measures— such as waking watches—to ensure life safety for serious internal fire safety issues other...
Matched on
terms: fire
PFD report
69match
Walter Gordon Powley
Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of specific room risk assessments and oversight failures by regulatory bodies.
Matched on
terms: assessment, failure
PFD report
69match
Keith Holmes
Unmaintained electrical equipment during the COVID-19 pandemic increased fire risks, exacerbated by a failure to reassess these dangers and a lack of contingency planning for future lockdown scenarios.
Matched on
terms: failure, fire
HMICFRS recommendation
69match
FRS 2023-25 CoC Recommendations: Devon and Somerset Fire and Rescue Service
Cause of concern: The executive board recognises it needs to do more in prevention. But not enough progress has been made since our last inspection to make prevention a sufficiently high priority for the service. The service should implement a robust and consistent method of prioritising its home safety visits to those most at risk and make sure...
Matched on
terms: fire
CQC action
68match
Archers Point Residential Home
The provider must ensure risks to people's health and safety are effectively assessed and managed, including developing risk assessments and guidance for epilepsy, equipment use (e.g., mobility aids, chairs), call bells, and behaviours, conducting maintenance checks on wheelchairs, creating person-centred Personal Emergency Evacuation Plans (PEEPS), embedding fire drills, and ensuring Do Not Attempt to Resuscitate (DNAR) forms are...
Matched on
terms: assessment, fire
Inquiry recommendation
66match
POPP-A.16 - Fire authorities must inspect stadia and restrict stands with inadequate fire precautions.
Fire authorities should identify and visit all sports stadia in their areas and should prohibit or restrict the use of any stands which, in their view, constitute a risk to spectators because of the inadequacy of the fire precautions.
Matched on
terms: fire
Inquiry recommendation
66match
P1-38 - Require quarterly fire door checks
The owner and manager of every residential building containing separate dwellings (whether or not they are high-rise buildings) be required by law to carry out checks at not less than three-monthly intervals to ensure that all fire doors are fitted with effective self-closing devices in working order.
Matched on
terms: fire
Inquiry recommendation
66match
P1-37 - Urgent fire door inspections required
The owner and manager of every residential building containing separate dwellings (whether or not they are high-rise buildings) carry out an urgent inspection of all fire doors to ensure that they comply with applicable legislative standards.
Matched on
terms: fire
Inquiry recommendation
66match
P1-8 - Require monthly firefighter lift inspections
The owner and manager of every high-rise residential building be required by law to carry out regular inspections of any lifts that are designed to be used by firefighters in an emergency and to report the results of such inspections to their local fire and rescue service at monthly intervals.
Matched on
terms: fire
Committee recommendation
66match
#21 - Wider aspects like fire safety and charge point placement require further attention for EV transition
In addition to removing barriers to charge point rollout, enabling the transition to electric vehicles requires addressing wider aspects such as ensuring that charge point demand is considered when new major road schemes are created, and fire safety techniques are updated.38 In written correspondence provided after our evidence session the Department stated that, while electric vehicles have not...
Matched on
terms: fire
PFD report
65match
Emma Waring
The absence of compulsory automatic water suppression systems in residential properties, especially for vulnerable individuals, represents a significant fire safety risk.
Matched on
terms: fire
PFD report
65match
George Hines
Defects in the pull-cord alarm system were unaddressed, residents were responsible for smoke detector maintenance, and smoke detectors were not linked to the emergency control room, delaying fire alerts.
Matched on
terms: fire
PFD report
65match
Ellen Kelly
Residential fire safety is compromised by flat front doors lacking self-closing mechanisms and failing to meet 30-minute fire resistance standards, leading to rapid fire spread and trapping residents.
Matched on
terms: fire
PFD report
65match
Ian Leak
The communal fire alarm system at Honiton Oaks failed to trigger audible alerts within individual flats, raising serious safety concerns for residents, particularly those with mobility problems under a "Stay Put" policy.
Matched on
terms: fire
PFD report
65match
Christopher Brookes
Security guards failed to respond to an activated fire exit alarm at a location with a history of a near-fall incident, indicating inadequate safety protocols and response.
Matched on
terms: fire
PFD report
65match
Mihaela Lazar
Inadequate fire detection and warning systems, including missing smoke alarms and kitchen doors, combined with unacceptable escape routes in older maisonettes, pose a significant fire risk in thousands of properties.
Matched on
terms: fire
PFD report
65match
Brian Frost
Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits failed to conduct health and safety risk assessments.
Matched on
terms: assessment
PFD report
65match
Canon Frost
Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits failed to conduct health and safety risk assessments.
Matched on
terms: assessment
PFD report
65match
Peter Moran
Carers failed to properly turn off a cooker before removing knobs for a fire-risk patient, and the knob removal method itself was inadequate to ensure appliance safety.
Matched on
terms: fire
PFD report
65match
James Golds
Inadequate guidance exists for managing fire risk in supported accommodation for vulnerable residents, exacerbated by no statutory sprinkler requirement and ineffective smoke detector placement.
Matched on
terms: fire
PFD report
65match
Barry Martin
Following forced police entry, an occupied house was left with its main exit boarded up and the secondary exit unusable, creating a significant fire safety risk by denying residents alternative escape routes.
Matched on
terms: fire
HMICFRS recommendation
65match
FRS 2023-25 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service doesn’t have enough trained and experienced protection staff to implement its risk-based inspection programme and take proportionate action to reduce risk and enforce fire safety regulations. Recommendation: Within 28 days, the service should provide an action plan which shows how it will provide resilient fire safety advice 24 hours a day, 7 days...
Matched on
terms: fire
HMICFRS recommendation
65match
FRS 2023-25 CoC Recommendations: Buckinghamshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since our last inspection to address its areas for improvement and provide clear direction to make sure that its teams can prioritise work according to risk. Recommendation: Within 28 days, the service should provide an action plan that clearly defines its risk-based inspection programme, within a revised protection strategy, which...
Matched on
terms: fire
Committee recommendation
65match
#2 - Sixteenth Report - Progress in remediating dangerous cladding
The Department is not fully funding the replacement of forms of dangerous cladding which are different from that used on Grenfell Tower, nor is it prioritising spending according to greatest risks or need. While the Department has established a new Building Safety Fund to finance the replacement of other forms of unsafe cladding, it has not provided a...
Matched on
terms: assessment
CQC action
65match
Darenth Grange Residential Home
The provider should ensure robust action is taken when staff do not act correctly during fire safety drills to fully protect people against the risk of fire.
Matched on
terms: fire
CQC action
65match
Clarendon Gardens
ensure a fire risk assessment was in place
Matched on
terms: assessment, fire
IMB recommendation
65match
Elmley (2024)
Prisoners - and staff - are at substantial risk of serious harm due to the fire safety issues on house block 5. The Minister must take urgent action to address this very worrying problem and preclude its use as a residential house block until the risk is effectively mitigated.
Matched on
terms: fire
Committee recommendation
64match
#21 - Seventh Report - Building Safety: Remediation and Funding
The evidence we received clearly indicates that it should be the regulator—and not building owners—who decides whether a building needs a fire risk assessment. As such, we recommend that the Building Safety Regulator decides whether a building needs a fire risk assessment; sets the standard that a building need to meet; sets out the methodology for undertaking assessments;...
Matched on
terms: assessment, fire
LGO / SPSO decision
64match
24-003-681 - Lancashire Fire & Rescue Service
Summary: We will not investigate this complaint about the Authority’s actions relating to a Fire Risk Assessment. It was reasonable for him to take the matter to court.
Matched on
terms: assessment, fire
Committee recommendation
64match
#6 - Sixteenth Report - Progress in remediating dangerous cladding
In a review commissioned jointly by the Department and the Home Office in the wake of the Grenfell Tower fire, Dame Judith Hackitt found that the building regulatory system was “not fit for purpose” to protect high-rise buildings.16 While the Department stressed that it was the construction industry that was first and foremost to blame for the safety...
Matched on
terms: failure, fire
Inquiry recommendation
62match
FENN-121 - Install comprehensive fire and smoke detection with automatic extinguishing in stations.
Comprehensive fire and smoke detection equipment, providing for remote monitoring and automatic operation of extinguishing devices, shall be fitted in underground stations as appropriate.
Matched on
terms: fire
Inquiry recommendation
62match
FENN-41 - Cease oil and spirit treatment of timber risers; replace missing fire cleats
The treatment of timber risers and step boards with oil and spirit must cease. Missing fire cleats must be replaced.
Matched on
terms: fire
Inquiry recommendation
62match
P2-26 - Establish mandatory fire risk assessor accreditation
That the government establish a system of mandatory accreditation to certify the competence of fire risk assessors by setting standards for qualification and continuing professional development and such other measures as may be considered necessary or desirable. We think it necessary for an accreditation system to be mandatory in order to ensure the competence of all those who...
Matched on
terms: fire
PFD report
61match
Vera Lillian Steel
A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons or smocks to residents who smoke to prevent similar incidents.
Matched on
terms: fire
PFD report
61match
Magdalen Dwerryhouse
Poor communication led to a missed patient appointment. A health trust also failed to engage with the fire service, preventing vulnerable individuals from receiving crucial home safety checks due to a lack of information sharing.
Matched on
terms: fire
PFD report
61match
Santosh Muthiah
The inability to identify appliance details after severe fire damage hinders accurate defect pattern recognition, and inconsistent information sharing among Fire & Rescue Services impedes product safety investigations.
Matched on
terms: fire