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
Inquiry recommendation
82match
50 - Approach to fire and explosion protection
The regulations and related guidance notes should promote an approach to fire and explosion protection:- (i) which is integrated as between - — active and passive fire protection — different forms of passive fire protection, such as fire insulation and platform layout, and — fire protection and explosion protection (paras 19.87-95); (ii) in which the need for, and...
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
Ian Morley
A fresh risk assessment was not evidently prompted following a noted deterioration in the deceased's condition. Additionally, the report describes inadequate fire risk management at Greenrod Place.
Matched on
terms: assessment, fire
PFD report
73match
Pauline Taylor
The coroner raised concerns about the fire hazard of emollient creams with low paraffin content, citing inadequate warnings on packaging and insufficient awareness of these risks. Locala also did not update risk assessments after significant patient changes.
Matched on
terms: assessment, fire
PFD report
73match
Pauline Oakley
The coroner noted a lack of safety assessment for the patient's flat and its appliances during hospital discharge planning and via the Co-ordinate My Care Plan. Additionally, concerns were raised about the unmonitored fire alarm system in the flats.
Matched on
terms: assessment, fire
PFD report
73match
Sean Ennis
The coroner identifies gaps in applying safety measures from fire risk assessments. Concerns also include inconsistent Telecare provision for vulnerable individuals, often not linked to smoke alarms, and a lack of regular Person-Centred Risk Assessments.
Matched on
terms: assessment, 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
CQC action
73match
Liverpool Walk in Centre
Review the suitability of the premises and ensure all areas are fit for the purpose for which they are being used. The provider should review the fire safety risk assessments for the Liverpool Walk in Centre and ensure that any actions required are complete and ongoing fire safety management is effective.
Matched on
terms: assessment, fire
Scottish FAI
73match
Simon Midgley; Richard John Dyson
Owners or operators of hotels or similar sleeping accommodation in Scotland should, where appropriate to their operation, have in place up to date and robust procedures, informed by an assessment of risks, to ensure that ash from open fires in hotels is removed and disposed of in a safe manner, thereby avoiding the risk of fires being started...
Matched on
terms: assessment, fire
Inquiry recommendation
70match
51 - Fire water deluge survivability
The ability of the fire water deluge system, including the fire pump system, to survive severe accident conditions should be a feature of the Safety Case (para 19.100).
Matched on
terms: 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
Robert Wood
The coroner identified that the Fire Risk Assessment document's wording should be revised to prioritise review before changes in use or structural alterations. Further, the report describes a need to confirm the sufficiency of training for Junior Fire NCOs to recognise complex electrical overloading issues.
Matched on
terms: assessment, fire
PFD report
69match
Santosh Muthiah
The coroner raises concerns about the difficulty in identifying appliance manufacturers and models after severe fires, which hinders the detection of manufacturing defects and assessment of risks. There are also inconsistencies in how fire investigation findings are communicated to manufacturers and Trading Standards nationally.
Matched on
terms: assessment, fire
PFD report
69match
Brian MaClean
The coroner noted a lack of proactive risk assessment and understanding by Social Services regarding the deceased's fire risks. Concerns were raised about the absence of processes for fire risk identification, referrals to the fire service, and installation of appropriate fire suppression systems and assistive technology in properties by the housing provider.
Matched on
terms: assessment, fire
PFD report
69match
Bernard Hender
The coroner was not confident in Whirlpool's risk assessment processes to fully appreciate fire risk, noting the company's reluctance to rely on reported fire data. Concerns were also raised about insufficient public awareness regarding the magnitude of spontaneous combustion fire risks.
Matched on
terms: assessment, 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
69match
Royal Sussex County Hospital
The trust should complete all actions found in the fire risk assessments on wards Level 8a East and Level 8a West.
Matched on
terms: assessment, fire
Scottish FAI
69match
Alexandra Carmen Michaela Schwenger
Further publicity in relation to the obligations imposed by the Fire (Scotland) Act 2005 on those who provide sleeping accommodation in their own homes. b) Preparing and publishing a short and accessible summary setting out what is required of persons who make such provision. c) Identifying and publicising a list of persons able to assist with the preparation...
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 coroner noted the absence of compulsory inclusion of automatic water suppression systems (domestic sprinklers) in the design and building phases of residential properties, particularly those for vulnerable individuals, to enhance fire safety.
Matched on
terms: fire
PFD report
65match
Elizabeth Griffin
The coroner noted shortcomings in telecare systems, including the lack of directly linked fire alarms, client communication with responders, and staff training for fire incidents. Issues were also raised regarding the slow launch of appliance safety campaigns.
Matched on
terms: fire
PFD report
65match
Mihaela Lazar
The coroner identified inadequate fire safety provisions in maisonettes, noting a lack of early fire detection, warning systems, and protected escape routes from upper floors. Many older properties have not been upgraded to current standards, posing significant risk.
Matched on
terms: fire
PFD report
65match
Brian Frost
The coroner raised concerns about unsafe loose kitchen floor tiles acting as a trip hazard for a frail resident. Welfare visits by the diocese did not include health and safety or risk assessments, despite the resident's known frailty and history of falls, indicating a broader risk for other 'grace and favour' residents.
Matched on
terms: assessment
PFD report
65match
Canon Frost
Welfare visits to retired priests in 'grace and favour' properties did not include health and safety or risk assessments, even when residents had a history of falls and mobility issues. This meant significant trip hazards, such as loose floor tiles, were not identified or addressed in the deceased's home.
Matched on
terms: assessment
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
The York Hospital
The service must ensure fire risk assessments are up to date, thoroughly assessed and documented to meet best practice guidance. For example, they must ensure fire exits are clearly marked and have safe exit routes. They must ensure fire drills are completed regularly and audited.
Matched on
terms: assessment, fire
CQC action
65match
Scarborough Hospital
The service must ensure fire risk assessments are up to date, thoroughly assessed and documented to meet best practice guidance. For example, they must ensure fire exits are clearly marked and have safe exit routes. They must ensure fire drills are completed regularly and audited.
Matched on
terms: assessment, fire
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
Inquiry recommendation
64match
4 - Contents of the Safety Case
In furtherance of the objectives set out in para 2 above, the operator should be required to set out the following in the Safety Case:- (i) A demonstration that so far as is reasonably practicable hazards arising from the inventory of hydrocarbons (a) on the installation, and (b) in risers and pipelines connected to the installation both in...
Matched on
terms: assessment, 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
60 - Immediate assessment of smoke ingress
The regulatory body should ask operators which have not already done so to carry out forthwith an assessment of the risk of ingress of smoke or gas into the accommodation; and to fit smoke and gas detectors and implement ventilation shutdown arrangements as in recommendation 57, without waiting for legislation (para 19.173).
Matched on
terms: assessment
Inquiry recommendation
62match
54 - Immediate fire risk analysis by operators
The regulatory body should ask operators which have not already done so to undertake forthwith a fire risk analysis, without waiting for legislation (para 19.103).
Matched on
terms: fire
Inquiry recommendation
62match
52 - Hydrocarbon fire test interpretation
The regulatory body should work with the industry to obtain agreement on the interpretation for design purposes of its interim hydrocarbon fire test and other similar tests. If in the view of the regulatory body there exists a need for an improved test, such as a heat flux test, it should work with the industry in order to...
Matched on
terms: fire
Inquiry recommendation
62match
49 - Fire risk analysis requirement
Operators should be required by regulation to submit a fire risk analysis to the regulatory body for its acceptance (para 19.90).
Matched on
terms: 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