Fire risk assessment failures
Systemic failures in fire safety, including inadequate risk assessments and unaddressed actions, posing risks to residents.
Source spread
Where this theme appears
This theme appears across 17 independent accountability sources, so the source mix matters as much as the headline total.
129 inquiry recs
71 PFD reports
116 committee recs
67 CQC actions
70 HMICFRS recs
1 NAO rec
16 IMB recs
18 IMB reports
1 patient safety alert
4 Scottish FAIs
7 detention investigation recs
4 DHR recs
66 LGO/SPSO decisions
2 CQC enforcement actions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(129)— showing 50 strongest matches
61 — Studies on breathable air in the TSR
Recommendation: Studies should be carried out with the objective of assisting designers in predicting the breathability of air in a TSR where its external fire wall is subjected to a severe hydrocarbon fire (para 19.163).
Unknown
60 — Immediate assessment of smoke ingress
Recommendation: 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 …
Unknown
57 — Ventilation intakes and detectors
Recommendation: For the purpose of maintaining breathable air within the accommodation, it should be required by regulation that the ventilation air intakes should be provided with smoke and gas detectors and that on smoke or gas alarm the ventilation and dampers …
Unknown
56 — Protection of accommodation
Recommendation: The regulations and the related guidance notes should promote an approach to protection of the accommodation:- (i) in which external fire protection is provided both to prevent breach of the accommodation and to maintain breathable air within it (para 19.170); …
Unknown
54 — Immediate fire risk analysis by operators
Recommendation: 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).
Unknown
52 — Hydrocarbon fire test interpretation
Recommendation: 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 …
Unknown
51 — Fire water deluge survivability
Recommendation: 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).
Unknown
50 — Approach to fire and explosion protection
Recommendation: 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 …
Unknown
49 — Fire risk analysis requirement
Recommendation: Operators should be required by regulation to submit a fire risk analysis to the regulatory body for its acceptance (para 19.90).
Unknown
46 — Studies on riser protection and SSIVs
Recommendation: Studies should be carried out with the following objectives:- (i) To achieve effective passive fire protection of risers without aggravating corrosion (para 19.22). (ii) To improve the reliability and reduce the cost of SSIVs so that it is more often …
Unknown
FENN-121 — Install comprehensive fire and smoke detection with automatic extinguishing in stations.
Recommendation: Comprehensive fire and smoke detection equipment, providing for remote monitoring and automatic operation of extinguishing devices, shall be fitted in underground stations as appropriate.
Unknown
FENN-41 — Cease oil and spirit treatment of timber risers; replace missing fire cleats
Recommendation: The treatment of timber risers and step boards with oil and spirit must cease. Missing fire cleats must be replaced.
Unknown
FENN-36 — Urgently replace wooden escalator risers due to 'trench effect' discovery
Recommendation: Replacement of the wooden risers must be urgently sought in view of the discovery of the 'trench effect' and the conclusions of the report referred to in Appendix G as Report 4n.
Unknown
POPP-A.16 — Fire authorities must inspect stadia and restrict stands with inadequate fire precautions.
Recommendation: 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.
Unknown
P2-26 — Establish mandatory fire risk assessor accreditation
Recommendation: 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 …
Gov response: The government accepts this recommendation. We will legislate to make it a mandatory requirement for fire risk assessors to have the competence to perform this critical role independently verified by a UKAS-accredited Certification Body.
Accepted
P2-10 — Require fire safety strategy from registered fire engineer at Gateway 2
Recommendation: 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 …
Gov response: The government accepts this recommendation. A fire safety strategy is already required with building control applications for the construction of and significant work to higher-risk buildings. The Building Safety Regulator will consider how to make …
Accepted
P1-39 — Require compliant flat entrance doors where unsafe cladding exists
Recommendation: All those who have responsibility in whatever capacity for the condition of the entrance doors to individual flats in high-rise residential buildings, whose external walls incorporate unsafe cladding, be required by law to ensure that such doors comply with current …
Gov response: The Home Office’s upcoming Fire Safety Bill will aim to clarify the scope of the Regulatory Reform (Fire Safety) Order 2005 – the ‘Fire Safety Order’ – to put beyond doubt that building owners or …
Accepted in part
P1-38 — Require quarterly fire door checks
Recommendation: 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 …
Gov response: The Home Office’s upcoming Fire Safety Bill will aim to clarify the scope of the Regulatory Reform (Fire Safety) Order 2005 – the ‘Fire Safety Order’ – to put beyond doubt that building owners or …
Accepted in part
P1-37 — Urgent fire door inspections required
Recommendation: 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.
Gov response: Sir Martin recommended that building owners or the responsible persons carry out urgent checks to ensure fire doors complied with current standards. MHCLG has recommended that all fire doors, including their closers, should be routinely …
Noted
P1-9 — Require monthly lift control mechanism tests
Recommendation: The owner and manager of every high-rise residential building be required by law to carry out regular tests of the mechanism which allows firefighters to take control of the lifts and to inform their local fire and rescue service at …
Gov response: Sir Martin Moore-Bick’s Phase 1 report was exhaustive in detail and made a series of findings and recommendations relevant to government. As the Prime Minister and the Secretary of State for Housing, Communities and Local …
Accepted in part
P1-8 — Require monthly firefighter lift inspections
Recommendation: 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 …
Gov response: Sir Martin Moore-Bick’s Phase 1 report was exhaustive in detail and made a series of findings and recommendations relevant to government. As the Prime Minister and the Secretary of State for Housing, Communities and Local …
Accepted in part
P1-6 — Require premises information boxes
Recommendation: The owner and manager of every high-rise residential building be required by law to ensure that the building contains a premises information box, the contents of which must include a copy of the up-to-date floor plans and information about the …
Gov response: Sir Martin Moore-Bick’s Phase 1 report was exhaustive in detail and made a series of findings and recommendations relevant to government. As the Prime Minister and the Secretary of State for Housing, Communities and Local …
Accepted in part
P1-5 — Require building floor plans for fire services
Recommendation: 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 …
Gov response: Sir Martin Moore-Bick’s Phase 1 report was exhaustive in detail and made a series of findings and recommendations relevant to government. As the Prime Minister and the Secretary of State for Housing, Communities and Local …
Accepted in part
70 — Availability standards for protective systems
Recommendation: Where a regulation imposes a requirement for a major emergency or protective system, such as a fire deluge system, it should be required that the operator should set acceptance standards for its availability (para 19.199).
Unknown
45 — Studies on inventory and pipeline connections
Recommendation: Studies should be carried out with the following objectives:- (i) To explore the feasibility of dumping in an emergency large oil inventories, such as those in the separators, in a safe and environmentally acceptable manner, so as to minimise the …
Unknown
5 — Design accidental events and acceptance standards
Recommendation: For the purposes of the demonstration referred to in para (iii) of recommendation 4, the accidental events are to be identified by the operator. A design accidental event is an event which will not cause the loss of any of …
Unknown
4 — Contents of the Safety Case
Recommendation: 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 …
Unknown
FENN-136 — Fire authority and RI to scrutinise new station designs for passenger safety.
Recommendation: The designs for new stations or significant alterations to stations shall be scrutinised by the fire authority and the Railway Inspectorate with special regard to passenger safety and fire precautions.
Unknown
FENN-127 — Re-examine Code of Practice regarding fire-loadings in escalator shafts and stations.
Recommendation: London Underground shall re-examine its Code of Practice as it relates to the fire-loadings in escalator shafts and other regions of stations.
Unknown
FENN-123 — Consult LFB and RI on fire safety for future station refurbishments.
Recommendation: London Undergound shall consult the London Fire Brigade and Railway Inspectorate about the means of escape and fire precaution measures in all future station refurbishment schemes.
Unknown
FENN-122 — Initiate research into paint fire qualities for London Underground Code of Practice.
Recommendation: London Underground shall initiate a programme of research into the fire qualities of paint. The surface to which it is applied and the method of application must be considered. The result of this research must be incorporated in the Code …
Unknown
FENN-86 — Review station staff fire and safety training based on consultant advice
Recommendation: Fire and safety training for station staff shall be reviewed in the light of the advice from consultants.
Unknown
FENN-85 — Provide fire safety training for cleaning and engineering staff on stations
Recommendation: Fire safety training for cleaning and engineering staff working on stations shall be provided. London Underground must obtain expert advice.
Unknown
FENN-83 — Provide biannual fire and safety training for non-supervisory and shop staff
Recommendation: Every six months fire and safety training must be provided for non-supervisory staff and booking clerks. Staff must be given site familiarisation training before they are permitted to take part in the running of the station. Specific provision shall be …
Unknown
FENN-81 — Establish continuing fire and safety instruction for station staff by supervisors
Recommendation: London Underground shall establish a programme of continuing instruction at work by supervisors for station staff in fire and safety with the assistance of the London Fire Brigade and British Transport Police. At stations equipped with water fog equipment supervisors …
Unknown
FENN-74 — Prohibit unprotected storage of combustible items at all Underground stations
Recommendation: Combustible items such as paper and card shall not be stored at stations unless properly protected from the risk of fire. This recommendation and the Code of Practice shall apply to all occupiers of premises on the Underground.
Unknown
FENN-69 — Survey system materials, evaluate risks, and remove hazardous materials programme
Recommendation: London Underground shall survey materials present on the system, evaluate the risks involved from those materials and devise a programme to remove those which constitute a hazard.
Unknown
FENN-53 — Implement regular cleaning of machine rooms and shafts with safe material storage
Recommendation: All machine rooms and shafts must be specially cleaned by the end of I988 and regularly cleaned thereafter. Essential cleaning materials shall be kept only in small quantities and in correctly marked containers in fire-proof bins.
Unknown
FENN-52 — Survey VIR cables, improve machine rooms, and waterproof electrical equipment for cleaning
Recommendation: A survey must be carried out of all remaining VIR cable installations and a renewal programme established. The electrical wiring, lighting, decoration, and general state of machine rooms and shafts must be improved. The waterproofing of electrical equipment to permit …
Unknown
FENN-49 — Check station ventilation and issue fire action instructions for contaminated air
Recommendation: Station ventilation systems must be checked to ensure that contaminated air cannot be introduced into the rooms they serve. Instructions must be issued on any action to be taken in the event of a fire.
Unknown
FENN-45 — Regularly examine fire equipment, report defects, and ensure immediate remedy
Recommendation: London Underground shall regularly examine fire equipment and ensure that defects are reported and remedied at once or alternative arrangements made.
Unknown
FENN-42 — Research escalator shaft fire dynamics using models and computer simulation
Recommendation: Further research shall be undertaken into the dynamics of fires in escalator shafts by London Underground using the available scale models and computer simulation.
Unknown
FENN-40 — Require station supervisors to inspect escalators and machine rooms every two hours
Recommendation: Station supervisors must personally inspect escalators, and both upper and lower machine rooms, every two hours until wooden parts have been removed.
Unknown
FENN-39 — Implement regular escalator cleaning, improving access and protective clothing for staff
Recommendation: Escalators shall be manually cleaned at least every six months until the rewiring of machine rooms is completed. Thereafter they shall be mechanically cleaned in accordance with the programme determined under Recommendation 38. Escalator steps must be removed as necessary, …
Unknown
FENN-35 — Replace wooden escalator skirting, balustrade, decking, and panels with metal
Recommendation: The wooden skirting boards and balustrade, decking and advertisement panels of all escalators must be replaced with metal by July 1989.
Unknown
FENN-21 — LFB to attend construction meetings, register risks, relocate affected equipment
Recommendation: The London Fire Brigade shall attend all pre-start meetings and important later meetings in relation to construction works on the Underground. Details of the works shall be included on the Fire Brigade's central risks register. Fire equipment and London Fire …
Unknown
FENN-20 — Produce and maintain up-to-date station plans in LFB-agreed locations
Recommendation: In agreement with the London Fire Brigade, London Underground shall produce and maintain up-to-date station plans, and place them in boxes it has provided, at locations agreed or specified by the London Fire Brigade.
Unknown
FENN-16 — Research air movement and provide criteria for safe train operation during fire
Recommendation: London Underground shall undertake further research into the effect of trains on air movement in the Underground. London Underground should provide criteria by which line controllers, who have received a report of fire, can judge whether it is safe to …
Unknown
FENN-15 — Modify London Underground fire equipment to London Fire Brigade standards
Recommendation: London Underground fire equipment shall be modified to London Fire Brigade standards and the amount and type of fire equipment in stations agreed.
Unknown
FENN-1 — Install heat and smoke detectors on escalator trusses and machine rooms
Recommendation: All escalator trusses shall be fitted with linear heat detectors and machine rooms with smoke detectors. Priority should be given to escalators with wooden components and consideration given to moving the water fog valves to a protected location outside the …
Unknown
Prevention of Future Deaths reports(71)— showing 50 strongest matches
Alan Smith
Concerns: The coroner noted a co-worker had not received specific training for working at height. Generic risk assessment forms and method statements were available but not routinely used by employees.
Overdue
Vera Lillian Steel
Concerns: The coroner noted the availability of fire protective aprons for smokers and raised concerns that care homes are not encouraged to provide access to these measures for residents who smoke, following an incident where a resident's clothing caught fire.
Overdue
Walter Gordon Powley
Concerns: Uncovered, high-temperature radiator pipes and valves exceeded safety guidance, posing a burn risk. The room lacked a physical risk assessment, and regulatory body inspections had not identified these issues.
Response (CQC): • The CQC stated it would share the report's findings within its organisation. • The CQC is piloting a new methodology that will assess services against five domains, including a … (AI summary)
Response (Health Safety Executive): • HSE stated its intention to raise the issue of assessing the risk from hot surfaces and pipe-work at the next meeting of the GB Social Care Partners Forum. • … (AI summary)
Response (RNHA): • The Association regularly advises its members on their responsibilities under the Health & Safety at Work Act. • The Association specifically advises members on the need to ensure pipes … (AI summary)
Responded
Magdalen Dwerryhouse
Concerns: The Trust's process for appointment follow-up lacked family involvement and communication. Additionally, the development of a partnership with Greater Manchester Fire and Rescue Service to share information for home safety checks for vulnerable individuals was hindered.
Response (5 Borough Partnership NHS Trust): • The Trust reviewed and amended operational guidance for community teams regarding missed appointments, including an immediate change in practice for Assessment Teams to contact referrers within 24 hours of … (AI summary)
Responded
Robert Wood
Concerns: 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.
Response: • The Defence Fire Risk Management Organisation (DFRMO) Fire Diary was amended to require advice from a competent fire risk assessor before premise changes and to provide additional guidance on … (AI summary)
Responded
Santosh Muthiah
Concerns: 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.
Response (AMDEA): • AMDEA ensures Fire & Rescue Services are supplied with contact details for its members. • AMDEA's Technical Manager prepared a proposal for changes to international standard IEC 60335-2-24, which … (AI summary)
Response (BSI): • The UK submitted proposals to the International Electrotechnical Commission (IEC) SC 61C for a flame retardant covering over foam insulation and improved testing for the fire resistance of outer … (AI summary)
Response (Forensic Sciences): • The Chartered Society of Forensic Sciences stated that it is not placed or required to report information regarding specific appliances or apparatus that may have caused a fire. • … (AI summary)
Response (Chief Fire Officers Association): • CFOA has been engaged in work since early 2014 to improve information sharing between Fire and Rescue Services (FRS) and Trading Standards (TS). • CFOA will continue to engage … (AI summary)
Response (Department for Business Innovation Skills): • The Department for Business, Innovation and Skills (BIS) will continue to support industry efforts to develop a proposal for white goods to carry key information on a fire-resistant plate. (AI summary)
Responded
Richard Turner
Concerns: The coroner identified a lack of standard procedures to regularly remind employees of lifting plans, associated risks, and health and safety issues, which could lead to complacency. There was also limited evidence of recent "Toolbox Talks."
Overdue
Christopher Butler
Concerns: The coroner noted a fault, which may not be revealed by electric testing, could be present in other similar properties and suggested the Fire and Rescue Service consider how to alert the local community.
Response (Oxfordshire County Council): • Oxfordshire County Council Fire and Rescue Service (OCCFRS) undertook a comprehensive review of the incident and is improving its risk management processes. • OCCFRS wrote to residents in similar … (AI summary)
Responded
Anne Fowler
Concerns: The coroner identified that smoke alarm covers were left in place after fitting, potentially preventing them from activating, and notes alarms were often inaccessible due to their ceiling location.
Overdue
Robert Spring
Concerns: There was no direct mechanism for the hospital to notify the fire service of high-risk home oxygen users who smoke, as the oxygen supplier's system prevented full disclosure of the smoking risk. This meant the patient was not assessed for specialist safety equipment, highlighting a need for improved inter-agency communication.
Response (United Lincolnshire Hospitals NHS Trust): • United Lincolnshire Hospitals NHS Trust (ULHT) met with Lincolnshire Fire & Rescue (LF&R) and Air Liquide to agree a new information-sharing process, which has been incorporated into Trust policy. … (AI summary)
Responded
Kenneth Bailey
Concerns: The coroner noted concerns regarding the limited operating hours of the local fire station, which resulted in a delay in fire service arrival and prompted unqualified individuals to attempt a rescue, placing themselves at risk.
Response (Greater Manchester Fire and Rescue Service): • Greater Manchester Fire and Rescue Service approved a revised duty system for Mossley Fire Station on 23 July 2015, based on 12 wholetime staff providing 24-hour cover. • A … (AI summary)
Responded
Ian Morley
Concerns: 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.
Overdue
Christianne Shepherd
Concerns: The coroner identifies a lack of a central register for energy sources and service history in holiday accommodations, alongside insufficient health and safety checks conducted by appropriately qualified specialists. Concerns also include inadequate information for travellers about carbon monoxide risks and the need for stronger EU legislation on gas installations.
Overdue
Emma Waring
Concerns: 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.
Response (RBH): • RBH properties are fitted with hard-wired smoke detection systems. • RBH established a Service Level Agreement with Greater Manchester Fire and Rescue Service for Safe & Well visits to … (AI summary)
Responded
George Hines
Concerns: Insufficient maintenance of emergency pull-cords and smoke detectors in sheltered accommodation, including a disconnected pull-cord, was noted. The smoke detector system also did not alert the Emergency Control Room, and fire instructions were unclear, risking delayed emergency response.
Overdue
Andrew Coates
Concerns: The coroner noted concerns regarding the suitability of a wooden shed as a firework store, particularly its licence for 1000 kg and the presence of other combustible materials. The licence was also deficient, failing to designate a specific site or type of explosive, and inspection records were incomplete.
Response (Cumbria County Council): • Cumbria County Council provided training to all operational Trading Standards Officers and fireworks administrators on The Explosives Regulations 2014, specifically covering storage and licensing requirements. • The Council reviewed … (AI summary)
Responded
Christine Dryden
Concerns: The coroner noted the absence of regular checks on smoke and heat detectors in the property. The report called for a review of existing arrangements for maintaining and carrying out periodic checks on these devices.
Overdue
Ellen Kelly
Concerns: The coroner noted concerns regarding fire safety, specifically that front doors of flats likely lack proper self-closing mechanisms and do not comply with the 30-minute fire-resistant British Standard.
Response (London Borough of Camden): • The London Borough of Camden completed a £5m programme of fire safety works to 4,500 high priority housing properties, which included renewing or upgrading flat entrance doors to FD30s … (AI summary)
Responded
Patrick Woods
Concerns: The coroner noted that the hospital's equipment portfolio was unknown, which prevented the identification of potentially dangerous equipment, subsequent risk assessment, and actions to prevent future harm to patients.
Response (Draeger Medical UK Limited): • Draeger updated its training documentation, including the Basic Skills Checklist, Workbook, Quick Guide, Practical Exercises, PowerPoint presentation, and Training Needs Analysis, to enhance clinician competence regarding machine functionality and … (AI summary)
Response (Luton Dunstable University Hospital): • The Trust stated it maintains an electronic database of all equipment, including location, service history, and risk categorization. • The Trust confirmed that incidents involving equipment are reviewed by … (AI summary)
Responded
John Wilson
Concerns: The coroner identified gaps in Beko's product recall communication, noting that notices sent by standard mail lacked delivery confirmation and follow-up attempts were insufficient, resulting in the deceased being unaware of a hazardous recalled appliance.
Overdue
Pauline Taylor
Concerns: 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.
Response (Medicines and Healthcare Products Regulatory Agency): • The MHRA is undertaking an in-depth review of instructions for use and reported adverse incidents, aiming to complete it by the end of 2017 and consider publishing additional safety … (AI summary)
Response (PAGB): • PAGB is developing new warning statements for product packaging and patient information leaflets, which will undergo user-testing to ensure clarity. • PAGB will work with the MHRA and other … (AI summary)
Response (Locala): • Locala disseminated updated guidance on paraffin-containing skin products and their fire risk to all business units and staff. • Training was updated, and risk assessment processes were revised to … (AI summary)
Response (NHS England): • The NHS Patient Safety Team undertook work with the Medicines and Healthcare Regulatory Agency and other organisations regarding the concerns. • Actions taken were detailed in the Patient safety … (AI summary)
Response (United Kingdom Home Care Association): • The United Kingdom Homecare Association published a fact sheet, 'UKHCA Guidance; Emollient Products Guidance for homecare providers,' in January 2018. • The United Kingdom Homecare Association published an article, … (AI summary)
Overdue
Russell Sherwood
Concerns: The Fire Service unit departed a dangerous flooding scene without ensuring the road was closed or warning signs were left. South Wales Fire and Rescue Service units lack equipment and protocols to close roads, relying on other authorities to do so.
Response (South Wales Fire and Rescue Services): • The Service is considering the recommendations as part of its response to the Fire Rescue Services (Emergencies)(Wales)(Amendment) Order 2017. • The Service is conducting a comprehensive review of its … (AI summary)
Responded
Rasikaben Chauhan
Concerns: The coroner noted a lack of clarity regarding whether awareness about a specific risk had been raised at local or national levels with relevant community and religious organisations.
Response (Northampton County Council): • Northamptonshire Fire and Rescue Service (NFRS) made the risks and circumstances of the death known to other UK Fire Services via a national communication tool. • NFRS delivered specific … (AI summary)
Overdue
Sharon Soares
Concerns: Concerns were raised regarding Bio Ethanol burners, which have been linked to at least a second fatality in the area, alongside previous deaths and numerous accidental injuries reported nationally.
Overdue
Brian MaClean
Concerns: 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.
Response (Manchester City Council): • All contacts closed or viewed as non-urgent by the involved officers have been reviewed. • Further training will be provided for all Contact Centre staff regarding the Care Act, … (AI summary)
Overdue
Ian Leak
Concerns: The coroner raised concerns that the 'Stay Put' policy and independent fire alarm systems at Honiton Oaks did not provide adequate external monitoring for individual flats, especially for residents with mobility problems who might struggle to escape during a fire.
Response (Peak Valley Housiing Asscoiation): • The organisation approved a design for improvements to the fire alarm systems at Honiton Oaks. • The design includes the installation of combined heat and smoke detectors in residents' … (AI summary)
Overdue
Bernard Hender
Concerns: 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.
Response (Whirlpool UK Appliances Limited): • Whirlpool stated it continues to apply its comprehensive product safety processes, including monitoring field reports for fire risks, and confirmed it would continue to cooperate with Trading Standards. • … (AI summary)
Responded
Sheila Gaskin
Concerns: Despite an identified risk of the deceased smoking in bed, the care plan did not prohibit carers from assisting with this, which occurred regularly. Management also lacked effective day-to-day oversight of this activity.
Response (CSSIW): • CSSIW committed to issuing general guidance to care providers on assessing and mitigating smoking-related risks. • The guidance would advise that care workers would not ordinarily assist people to … (AI summary)
Response (CQC): • CQC clarified that the care provider for Ms Gaskin was not regulated by CQC. • CQC described its existing inspection methodology for regulated services, which includes assessing risk management … (AI summary)
Responded
John Nichols
Concerns: The Fire Drills Policy did not include sufficient safeguards for monitoring residents, particularly those with dementia, before, during, and after fire drills.
Response (Kings Lynn and Eastgate Residential Care Homes): • The organisation engaged a Fire Consultant to observe and comment on fire drill procedures. • The Group's Fire Drill Procedure, Pre-Assessment Procedure, and Personal Emergency Evacuation Plans (PEEPs) were … (AI summary)
Responded
Christopher Brookes
Concerns: The report highlights a previous near-fall incident at the location and a lack of response by security guards to an activated fire exit alarm.
Response (City of Wolverhampton): • The Council inspected and maintained the gate and its push pad mechanism. • The Council installed additional safety lighting and signage along the fire escape route. • The Council … (AI summary)
Overdue
Elizabeth Griffin
Concerns: 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.
Response (Department for Business Energy Industrial Strategy): • The Government established a new central recalls website in October 2016, which was upgraded in June 2017, to provide information on product recalls. • The Department commissioned the British … (AI summary)
Response (Whirlpool UK): • Whirlpool described its comprehensive product safety processes, including field monitoring, risk assessment, and reporting, stating these processes are applied on an ongoing basis. • Whirlpool detailed its advocacy for … (AI summary)
Response (CTSI): • The Chartered Trading Standards Institute stated it is a private company and professional body for trading standards officers. • The Institute indicated it does not have powers to get … (AI summary)
Overdue
Matthew Hatfield
Concerns: The coroner raises concerns about soldiers' clarity regarding the "Prove The Gun drill" and the Range Conducting Officer's up-to-date knowledge of tank status. The report also notes the need for improved risk assessments during gun design, actively considering drills.
Response (Ministry of Defence): • The Ministry of Defence revised Army Equipment Support Publications (AESPs) to clarify gun safety drills and mandate specific checks for critical components, with all Challenger 2 crews receiving comprehensive … (AI summary)
Response (BAE Systems): • BAE Systems and the MoD are developing a design solution to eliminate the risk of the Challenger 2 gun firing without a vital safety assembly. • Two additional engineering … (AI summary)
Responded
Mihaela Lazar
Concerns: 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.
Overdue
Kenneth Bardsley
Concerns: The coroner noted no formal qualification requirements for lift engineers and identified a gap where regulatory lift examination findings were not consistently read, acted upon, or escalated. Concerns were raised regarding the care home's system for managing lift examination reports and the lift company's processes.
Overdue
Brian Frost
Concerns: 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.
Overdue
Canon Frost
Concerns: 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.
Response: • The Diocese has reviewed its procedures for supporting retired priests living in diocesan accommodation. • Annual welfare visits will now include a Diocesan Surveyor to conduct full external and … (AI summary)
Overdue
Barnaby Aylward
Concerns: The coroner raised concerns regarding the absence of a multi-agency preventative approach to assess and manage risks from a social housing tenant's behaviours linked to his serious mental illness, including insufficient documentation of these risks in mental health care plans and clinical notes.
Response: • West Yorkshire Fire and Rescue Service (WYFRS) led a Serious Incident Review in October 2017, which included actions to review partnership arrangements and provide refresher training to partner staff. … (AI summary)
Overdue
Peter Moran
Concerns: The carer did not properly turn off a cooker despite instructions regarding fire risk, and removing cooker knobs was deemed an inappropriate method for ensuring appliance safety.
Response (AR1 Homecare Ltd): • AR1 Homecare updated its generic risk assessment to state that appliance knobs must not be removed and recommends requesting a Fire Officer visit. • The organisation provides staff training … (AI summary)
Responded
John Jennings
Concerns: Concerns were raised that a specific Code of Practice and British Standard 5839 LD1 Maximum Protection level for fire detection were not statutory requirements.
Response (Ministry of Housing, Communities and Local Government): • Officials have been asked to raise the matter of smoke alarm standards with the relevant committee at the British Standards Institute for consideration. • A full technical review of … (AI summary)
Responded
Pauline Oakley
Concerns: 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.
Response (East London NHS Foundation Trust): • The Trust stated that the case would be discussed with staff in regular team meetings to ensure lessons are learned. (AI summary)
Response (East End Homes): • The organisation confirmed domestic smoke alarms were fitted and last tested on 02/09/2019. • The organisation stated its Fire Safety leaflet advises residents to call the Fire Brigade if … (AI summary)
Response (GP): • The GP attended an Adult Safeguarding webinar on Hoarding and Fire Safety. • The practice clinical team agreed that in cases where a home environment safety concern is raised … (AI summary)
Responded
Jaden Francois-Espirit
Concerns: The coroner noted that Jaden's deteriorating mental well-being was not recognised, preventing access to available support. The report highlights the importance of recognising subtle signs of distress and exploring a request for help that is subsequently not utilised.
Response (London Fire Brigade): • The London Fire Brigade (LFB) accepted 24 recommendations from its internal investigation report and developed an action plan. • The action plan was extended to incorporate concerns raised in … (AI summary)
Responded
Darrell Spear
Concerns: Concerns included delays in addressing significant self-neglect and hoarding issues that posed a fire risk, despite agencies being aware. There was also poor inter-agency communication and no clear strategy to manage these identified risks.
Overdue
Netlyn Robinson
Concerns: The coroner noted a lack of processes to ensure vulnerable individuals have working alarms, telephones, and heating upon returning home. Concerns were also raised about the sufficiency of social worker training and clear guidance for assessing premises suitability for discharge.
Response (Leeds City Council): • Leeds City Council stated it would provide 'Lessons Learned' training sessions to the Mental Health Unit, focusing on telecare, discharge planning, and risk assessment. • The Council indicated it … (AI summary)
Responded
Henry Boddy
Concerns: The coroner noted a gap in enforcement powers to address fire risks in residential properties, particularly those arising from hoarding behaviour.
Response (Home Office): • The Home Office stated that the Regulatory Reform (Fire Safety) Order 2005 applies to communal areas of residential buildings, and Fire and Rescue Authorities (FRAs) can issue prohibition notices … (AI summary)
Overdue
James Golds
Concerns: The coroner identified insufficient guidance for care facilities on managing fire risk from residents and its escalation. Concerns also included the absence of a statutory requirement for sprinkler systems in such accommodation, alongside potentially delayed smoke detector activation.
Response (Department for Levelling Up Housing Communities): • The Government reduced the height threshold for mandatory sprinkler systems in new blocks of flats from 30 metres to 11 metres in November 2020. • A full technical review … (AI summary)
Responded
Barry Martin
Concerns: The coroner raised concerns that occupied houses boarded up after forced entry may lack alternative safe exit routes for residents, as was the case for Mr Martin.
Response (Jigsaw Homes Tameside): • Jigsaw Homes stated its usual process involves technicians checking for occupants and alternative exit routes before boarding up a door. • The technician who attended noted rear door access … (AI summary)
Responded
Christian Hinkley
Concerns: The coroner noted concerns regarding the unreliable fire detection system in prison cells, which cannot detect fires sufficiently early. Despite previous recommendations and knowledge of rapid fire progression, effective in-cell automatic fire detectors have not been installed.
Response (HM Prison and Probation Service): • The national programme for automatic fire safety systems, including in-cell detectors, is forecast to be completed within five to seven years. • The proposal for interim installation of in-cell … (AI summary)
Responded
Sean Ennis
Concerns: 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.
Response (Barnet Homes): • Barnet Homes stated it would now carry out Person Centred Risk Assessments on all Sheltered Housing tenants, with a target completion date for missing assessments. • Barnet Homes committed … (AI summary)
Response (Network Homes): • All tenants at Knightleas Court and other Network Homes schemes have had their Person-Centred Risk Assessments (PCRAs) reviewed since the fire. • Vulnerable residents identified as potentially requiring evacuation … (AI summary)
Response (CQC): • CQC inspectors received training in fire safety in supported housing, guided by National Fire Chiefs Council guidance. • CQC is working with the National Fire Chiefs Council to promote … (AI summary)
Responded
Ashleigh Timms
Concerns: Staff lacked competence in fire evacuation, and specialist housing fire alarms did not automatically alert emergency services. The coroner noted insufficient fire safety audits and a lack of clear guidance on managing high-risk electrical devices and digital locks.
Response (London Fire Brigade): • LFB addressed drafting ambiguity in its policy on vetting/review of fire safety regulatory audits by managers and promulgated this to staff. • LFB plans to conduct a regulatory audit … (AI summary)
Response (National Fire Chiefs Council): • The National Fire Chiefs Council (NFCC) stated it would report the coroner's concerns regarding staff competence, fire alarms, and automatic emergency service links to relevant committees and groups. • … (AI summary)
Response (Kennedys): • Sequence Care provides annual face-to-face fire safety training and specific induction training tailored to each premises for staff. • Annual competency assessments for staff have been revised and re-administered … (AI summary)
Response (British Standards Institution): • BSI's technical committees are reviewing fire safety standards BS 5839-1, BS 5839-6, BS 9991, and BS 7273-4. • Proposed changes include clarifying user responsibilities for fire detector reviews and … (AI summary)
Responded
Keith Holmes
Concerns: The coroner noted an increased risk of fire or accident from unmaintained electrical equipment during the Covid-19 pandemic, with P3 failing to reassess these risks. There is no contingency plan for managing such risks in future lockdowns.
Response (P3 Charity): • The organisation sought advice from OHEAP, the Health and Safety Executive, and the Fire Service regarding the concerns raised. • The organisation undertook a risk assessment on 17 April … (AI summary)
Responded
Select committee recommendations(116)— showing 50 strongest matches
#107 —
Recommendation: We recommend that the Government works with the EU to agree that lithium-ion batteries be assigned a hazardous List of Wastes code to support the reporting and management of the risks and to ensure that recycling is undertaken by responsible …
Response attribution not verified
#106 —
Recommendation: The Committee heard that at present, despite the unique handling that lithium-ion batteries require in terms of waste management and recycling, they do not have their own waste code and currently sit under a non- hazardous waste code with other …
Response attribution not verified
#16 —
Recommendation: Additional costs may also arrive through wider fire safety issues discovered during remediation works and need correction. The National Audit Office found that cladding inspection has revealed other significant flaws in construction and fire safety in many 42 Ministry of …
Response attribution not verified
#15 —
Recommendation: Private leaseholders’ emotional strain has been compounded by rising costs passed on to them by their building owners. These costs are often as a result of interim fire safety measures. The Department estimated a common interim measure, waking watches (overnight …
Response attribution not verified
#13 —
Recommendation: The number of residents living in buildings with unsafe cladding is not clear. The Department estimates there are over 20,000 homes in around 240 high-rise buildings yet to be remediated with unsafe cladding similar to that used on the Grenfell …
Response attribution not verified
#10 —
Recommendation: The Department said it was unacceptable that buildings of any height had unsafe cladding, not just high-rise buildings (i.e. those above 18 metres in height). Nevertheless, it said it was not funding the replacement of cladding in buildings below 18 …
Response attribution not verified
#7 —
Recommendation: Aluminium composite material cladding is not the only form of flammable cladding that has prompted serious safety concerns.19 In January 2020 the Department published 9 Q 19 10 Q 59 11 C&AG’s Report, paragraph 11 12 Hansard HC, 19 July …
Response attribution not verified
#2 —
Recommendation: 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 …
Response attribution not verified
#21 — Wider aspects like fire safety and charge point placement require further attention for EV transition
Recommendation: 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 …
Response attribution not verified
#34 — Inconsistent PAS 9980 fire risk appraisals lead to significant delays and disputes.
Recommendation: 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 …
Response attribution not verified
#32 — Insurance premiums will remain high without full property protection alongside life safety.
Recommendation: In written evidence, the ABI called on government to adopt an approach that priorities property protection and building resilience alongside risk to life. It said that without a standard requiring the removal of combustible material in external walls (insulation and …
Response attribution not verified
#18 — Limited qualified professionals compromise quality and consistency of PAS 9980 fire risk assessments.
Recommendation: 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 …
Response attribution not verified
#13 — Government funding programmes exclude non-cladding fire safety defects, burdening property owners and leaseholders.
Recommendation: 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 …
Response attribution not verified
#63 —
Recommendation: We recommend that the Government include supplementary provisions in the Bill for mandating regular electrical safety checks in higher-risk buildings. (Paragraph 188) Construction Products and Supplementary Provisions
Response attribution not verified
#21 —
Recommendation: 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 …
Response attribution not verified
#31 — Insurance premiums may remain high despite remediation due to PAS 9980 life safety focus.
Recommendation: MHCLG told us that, as well as options for intervening in the market to reduce premiums while buildings are awaiting remediation, it expected the insurance industry to hold to its word in reducing premiums as risk is reduced. It said …
Response attribution not verified
#3 —
Recommendation: The suggestion by some freeholders and their representatives that ground rent is a contribution towards building safety remediation is incorrect. Leaseholders do not believe and should not expect that ground rent is used as a proxy for an additional service …
Response status not verified
#23 —
Recommendation: The National Audit Office found that there has been a shortage of skills or personnel needed to complete remediation work.72 However, shortages are not restricted to the removal and replacement of cladding. The Local Government Association wrote to us outlining …
Response attribution not verified
#22 —
Recommendation: While leaseholders have been unable to move or remortgage, some have seen their insurances premiums rise significantly. For those in buildings with serious fire safety defects, there are examples of premiums rising by over 400%.69 This is on top of …
Response attribution not verified
#21 —
Recommendation: We made it clear to the Department that professional indemnity insurance has been regularly brought to our attention by the industry and needs sorting as a priority.67 The Department told us that it is working with the Fire Industry Association …
Response attribution not verified
#20 —
Recommendation: In response to our concern that leaseholders are receiving nil valuations, the Department told us that this is an “industry issue” but it is engaging with lenders and involving the Treasury on this.63 UK Finance wrote to us to say …
Response attribution not verified
#12 —
Recommendation: The Department understands there are around 40,000 care homes, sheltered homes, and hospitals (i.e. buildings with residents who might need significant assistance to evacuate) below 18 metres in England, of which 98% are below 11 metres (less than four storeys).40 …
Response attribution not verified
#11 —
Recommendation: One category of buildings below 18 metres that might present increased risks are care homes. In January 2020 the Department published advice from its independent expert advisory panel that buildings of any height with residents who need significant assistance to …
Response attribution not verified
#6 —
Recommendation: 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 …
Response attribution not verified
#1 —
Recommendation: On the basis of a report by the Comptroller and Auditor General, we took evidence from the Ministry of Housing, Communities and Local Government (the Department) about the remediation of dangerous of cladding on high-rise buildings.1
Response attribution not verified
#5 —
Recommendation: There is a shortage of specialist skills to support the remediation of buildings with unsafe cladding. There is a shortage of fire safety expertise, both in the enforcement and inspection of buildings with unsafe cladding; this has been a particular …
Response attribution not verified
#4 —
Recommendation: The Department has not done enough to address spiralling insurance costs and ‘nil’ mortgage valuations. Private leaseholders in blocks with dangerous cladding have received ‘nil’ valuations for their properties, meaning they have found it impossible to sell or remortgage, while …
Response attribution not verified
#3 —
Recommendation: The Department has no knowledge of how many care homes below 18 metres in height have dangerous cladding. The Department has published advice that the risks of unsafe cladding are increased for buildings, such as care homes, where there are …
Response attribution not verified
#71 —
Recommendation: We recommend that the Government set out, either in the Bill or in secondary legislation to be published alongside it, how the regime will certify individual products, as opposed to product families, and take account of products with more than …
Response attribution not verified
#70 —
Recommendation: The construction products regulatory regime envisaged in the Bill and accompanying documents fails to recognise that a single product may have more than one application and that it might be considered safety critical in one application but not in another. …
Response attribution not verified
#69 —
Recommendation: We recommend that the Government make provision, either in the Bill or in secondary legislation, for a testing regime that treats products as parts of systems, perhaps by mandating the provision of a certificate confirming how the product performs when …
Response attribution not verified
#68 —
Recommendation: We are persuaded that schedule 8 fails to treat products as parts of systems, though we recognise that discussions on this point are ongoing. The future testing regime must assess a product’s performance in combination with other products as well …
Response attribution not verified
#66 —
Recommendation: We recommend that the Government provide for the publication of test failures and re-run tests and for the establishment of an independent and unified system of third- party certification in order to introduce greater transparency and rigour into the regulation …
Response attribution not verified
#64 —
Recommendation: We strongly agree that there is insufficient clarity around the future product testing regime, although we acknowledge that discussions on the detail are ongoing. We recommend that the Government publish with the Bill its proposals for improving the product testing …
Response attribution not verified
#62 —
Recommendation: We agree that electrical safety should be an integral part of the building safety system and that the Bill is an opportunity to require regular electrical safety checks in higher-risk buildings. We are clear, however, that no further specific duties …
Response attribution not verified
#50 —
Recommendation: We agree that the role of building safety manager and the supply of adequately skilled individuals to fill the role will be critical to the success of the new building safety regime for higher-risk buildings. We also agree that without …
Response attribution not verified
#49 —
Recommendation: We agree that the safety case report is one of the most onerous responsibilities on the accountable person and that in order to prepare for implementation the industry will need to know what the safety case report will look like …
Response attribution not verified
#37 —
Recommendation: We understand the concern from the private building control profession about the conflict of interest arising from the regulator’s dual role as building control body for higher-risk buildings and regulator of the building control profession. While we recognise that starting …
Response attribution not verified
#35 —
Recommendation: We are concerned that the Bill only removes dutyholder choice in respect of higher- risk buildings. As a result, the majority of building control work will remain exposed to the weaknesses and conflicts of interest identified by Dame Judith Hackitt. …
Response attribution not verified
#33 —
Recommendation: We are concerned that the Government’s proposed extension of permitted development rights would allow many building projects to bypass Gateway one and thereby weaken the whole regulatory framework for the design and construction of higher-risk buildings. We urge the Government, …
Response attribution not verified
#31 —
Recommendation: We strongly recommend that the Government include provisions in the Bill itself for establishing a national system of third-party accreditation and registration for all professionals working on the design and construction of higher-risk buildings.
Response attribution not verified
#20 —
Recommendation: Given that the introduction of the PAS 9980 will not result in the elimination of EWS1 forms, we remain concerned that uncertainty will remain about the safety of buildings and will continue to stymie those trying to sell their homes. …
Response attribution not verified
#2 —
Recommendation: In the absence of PAS-79 guidance which was withdrawn in August 2021, it is imperative that the British Standards Institute publish its new standard as soon as possible. We urge the Government to report on its consultation on Personal Emergency …
Response attribution not verified
#8 —
Recommendation: Since the start of 2016, there have been 25 fire incidents within the Palace and 13 incidents of falling masonry.22 Nearly two hundred years ago, in 1834, the historic Palace was destroyed by a fire following delay restoring the building.23
Response attribution not verified
#6 — Palace of Westminster faces catastrophic damage risks, especially from fire incidents
Recommendation: The Clerks have legal responsibility for the safety of those working and using the Palace and the wider estate.9 The Clerk of the House of Commons told us he was very clear that eventually there will be ‘catastrophic and irreversible …
Response attribution not verified
#7 — Provide social housing providers with equal access to building safety remediation funds.
Recommendation: The Government’s focus on holding social housing providers responsible for remediating building safety work is producing an unhelpful disparity between the private and social housing sectors. There is no justification for private sector landlords to be treated more favourably. We …
Response attribution not verified
#6 — Necessary fire safety work imposes significant additional costs on social housing providers.
Recommendation: Necessary fire safety work has resulted in significant additional costs for social housing providers, as the Government has acknowledged in its written evidence.
Response attribution not verified
#74 —
Recommendation: We cannot judge the adequacy of European harmonised standards, but we agree with the industry that the Government should indicate soon whether it has any plans to review hENs and commission new standards. The Government should indicate whether or how …
Response attribution not verified
#73 —
Recommendation: We recommend that the Government make clear that the schedule as worded will cover such products or amend it so that it does.
Response attribution not verified
#72 —
Recommendation: It seems obvious that the provisions in Schedule 8 for the designation of European standards are intended to cover products with European technical assessments. It is less obvious why schedule 8 refers only to “other overseas standards”. We understand why …
Response attribution not verified
CQC inspection actions(67)— showing 50 strongest matches
Worthing Hospital
The trust must ensure equipment in ward and theatre environments is moved or stored in a suitable location and avoids emergency exits being blocked.
Must Do
Worthing Hospital
The trust must ensure equipment in ward environments is moved and stored in a suitable location and avoids emergency exits being blocked.
Must Do
William Harvey Hospital
The trust must ensure fire escape routes are kept clear and fire doors are kept closed.
Must Do
William Harvey Hospital
The trust must ensure fire extinguishers are maintained correctly
Must Do
William Harvey Hospital
The trust must ensure fire escape routes are kept clear and fire doors are always kept closed.
Must Do
William Harvey Hospital
The trust must ensure that fire safety risks associated with an overcrowded department are assessed and mitigated. For example, with regard to trolleys blocking corridors and fire exits.
Must Do
Westmorland General Hospital
The trust should ensure that fire doors are maintained and used correctly.
Should Do
University Hospital of Hartlepool
The service should ensure appropriate fire safety procedures and inspections are completed and records stored in line with trust policy.
Should Do
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 …
Must Do
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 …
Must Do
St Richard's Hospital
The trust must ensure equipment in ward and theatre environments is moved or stored in a suitable location and avoids emergency exits being blocked.
Must Do
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 …
Must Do
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 …
Must Do
Royal Sussex County Hospital
The trust must ensure equipment in ward environments is moved or stored in a suitable location and avoids emergency exits being blocked.
Must Do
Royal Sussex County Hospital
The trust must ensure equipment in ward and theatre environments is moved or stored to a suitable location and avoids emergency exits being blocked.
Must Do
Royal Shrewsbury Hospital
The service should ensure fire doors are in good working order at all times.
Should Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure fire escape routes are kept clear and fire doors are kept closed.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure fire extinguishers are maintained correctly
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure fire escape routes are kept clear and fire doors are always kept closed.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure that fire safety risks associated with an overcrowded department are assessed and mitigated. For example, with regard to trolleys blocking corridors and fire exits.
Must Do
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 …
Should Do
Ellesmere Port Hospital
The trust must ensure that fire exits are clear from obstruction and well maintained.
Must Do
Doncaster Royal Infirmary
The trust must ensure staff keep all daily cleaning records and (fire and defibrillator) safety checks up to date.
Must Do
Diana Princess of Wales Hospital
The trust should ensure that fire doors are closed at all times in line with trust policy
Should Do
Cumberland Infirmary
The trust should ensure that all staff adhere to fire safety protocol and cease wedging or holding open fire-resistant doors within the department. Regulation 12(2)(d).
Should Do
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.
Should Do
Southwinds
The provider did not ensure that the premises was safe as fire safety procedures were not followed.
Must Do
Park Cottages
People were not protected because the registered provider had not reasonable steps taken to mitigate the risks to people who used the service. There were not appropriate fire safety checks of the building.
Must Do
Barton Park Nursing Home
One of the fire door closures did not work correctly and there were further doors which were propped open around the home.
Must Do
Westwood Care Home
The provider had failed to ensure the fire and building standards were properly risk assessed and maintained.
Must Do
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.
Should Do
Clarendon Gardens
ensure a fire risk assessment was in place
Must Do
Barton Park Nursing Home
Fire doors were not being used appropriately which put people at risk of harm.
Must Do
The Princess Royal Hospital
The service should ensure fire doors are in good working order at all times.
Should Do
Mount Vernon Cancer Centre
The trust should ensure faults with the physical environment and premises are reported and fixed in a timely manner, including reported faults with the main entrance fire door.
Should Do
Verve Health
The service must ensure that regular fire drills are completed to ensure service users and staff are able to safely vacate the building in the event of an emergency.
Must Do
Serenity House
The provider had not ensured people were consistently provided with safe care and treatment. The risk of fire had not been sufficiently mitigated.
Must Do
Ashdale Care Home
The fire alarm system had a fault, this had not been investigated or resolved.
Must Do
The Everley Residential Care Home
We recommend that the registered provider ensures that there is no obstruction to prevent fire doors from operating correctly and that they are maintained to operate effectively.
Must Do
St Albans House
The provider should ensure there are specific details on how to evacuate people during the day and night.
Should Do
Psychiatry-UK LLP
The service should ensure staff working in head office have fire safety training and the building has suitable emergency signage.
Should Do
Pennine View
The provider should review fire safety procedures.
Should Do
Hey Baby 4D Halifax
The service should ensure fire alarm checks resume and are recorded in accordance with policy.
Should Do
Barron Winnicott Home
Systems were not in place or effective to ensure premises were safe in the event of a fire or to prevent unauthorised access.
Must Do
Park Grange Care Home
Procedures to protect people in the event of a fire were not robust and risks to people were not always effectively managed. We concluded the management of medicines was not always carried in a safe way.
Must Do
Etherley Lodge
The provider must ensure that premises and equipment are properly maintained and safe, including implementing fire safety control measures, having personal evacuation plans, robust maintenance mechanisms, and ensuring electrical items are tested and damp issues are addressed.
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurestaffkeepalldailycleaningrecordsand(fireanddefibrillator)safetychecksuptodate.Regulation12(2)(b)
Must Do
West Berkshire Community Hospital
Theserviceshoulddevelopaproceduretosafelystoreemptyoxygencylinderspriortothembeingcollected.
Should Do
Verve Health
This service must ensure that service users have Personal Emergency Evacuation Plan’s (PEEPs) in order to safely support them to evacuate the building in an emergency.
Must Do
The Newcastle Clinic
The service should have a fire evacuation record test book.
Should Do
HMICFRS recommendations(70)— showing 50 strongest matches
FRS 2018-19 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: West Sussex FRS doesn't have a clear strategy for using its risk-based inspection programme to identify the highest risk premises. The database it uses to manage premises information is unreliable and not always accurate. The service can't …
Recommendation
FRS 2018-19 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: West Sussex FRS doesn't have a clear strategy for using its risk-based inspection programme to identify the highest risk premises. The database it uses to manage premises information is unreliable and not always accurate. The service can't …
Recommendation
FRS 2018-19 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: Prevention activity doesn't always align with risks identified in the IRMP. Home fire safety checks aren't being done in a timely manner and there is a large backlog of high-risk cases. Recommendation: The service should ensure it …
Recommendation
FRS 2018-19 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: West Sussex FRS doesn't have a clear strategy for using its risk-based inspection programme to identify the highest risk premises. The database it uses to manage premises information is unreliable and not always accurate. The service can't …
Recommendation
FRS 2018-19 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: Prevention activity doesn't always align with risks identified in the IRMP. Home fire safety checks aren't being done in a timely manner and there is a large backlog of high-risk cases. Recommendation: The service should ensure it …
Recommendation
FRS 2023-25 CoC Recommendations: Warwickshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to determine its highest-risk premises to inform its risk-based inspection programme. Recommendation: Within 28 days, the service should review its action plan, detailing how it will review its …
Recommendation
FRS 2023-25 CoC Recommendations: Warwickshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to determine its highest-risk premises to inform its risk-based inspection programme. Recommendation: Within 28 days, the service should review its action plan, detailing how it will put in …
Recommendation
FRS 2023-25 CoC Recommendations: Warwickshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to determine its highest-risk premises to inform its risk-based inspection programme. Recommendation: Within 28 days, the service should review its action plan, detailing how it will develop a …
Recommendation
FRS 2021-22 CoC Recommendations: Warwickshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to determine its highest risk premises to inform its risk-based inspection programme. Recommendation: By 31 August 2021, the service should review its systems and processes for dealing with …
Recommendation
FRS 2021-22 CoC Recommendations: Warwickshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to determine its highest risk premises to inform its risk-based inspection programme. Recommendation: By 31 August 2021, the service should review its risk-based inspection programme to make sure …
Recommendation
FRS 2021-22 CoC Recommendations: Warwickshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to develop prevention activity that prioritises those most at risk of fire. Recommendation: By 31 August 2021, the service should put in place an effective system for joint …
Recommendation
FRS 2021-22 CoC Recommendations: Warwickshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to determine its highest risk premises to inform its risk-based inspection programme. Recommendation: By 31 August 2021, the service should put in place a clear plan with timescales …
Recommendation
FRS 2021-22 CoC Recommendations: Warwickshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to determine its highest risk premises to inform its risk-based inspection programme. Recommendation: By 31 August 2021, the service should develop a protection strategy with a resourced and …
Recommendation
FRS 2021-22 CoC Recommendations: Warwickshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to develop prevention activity that prioritises those most at risk of fire. Recommendation: By 31 August 2021, the service should develop a clear prevention strategy that prioritises the …
Recommendation
FRS 2023-25 CoC Recommendations: Surrey Fire and Rescue Service
Cause of concern: The service can't assure itself that its risk-based inspection programme prioritises the highest risks and includes proportionate activity to reduce risk. Recommendation: Within 28 days, the service should provide an action plan that shows how it will:- …
Recommendation
FRS 2023-25 CoC Recommendations: Surrey Fire and Rescue Service
Cause of concern: The service can't assure itself that its risk-based inspection programme prioritises the highest risks and includes proportionate activity to reduce risk. Recommendation: Within 28 days, the service should provide an action plan that shows how it will …
Recommendation
FRS 2021-22 CoC Recommendations: Norfolk Fire and Rescue Service
Cause of concern: The service hasn’t made prevention activity a high enough priority and it isn’t adequately identifying those most at risk from fire. Recommendation: By 28 February 2022, the service should put in place plans that are designed to …
Recommendation
FRS 2021-22 CoC Recommendations: Norfolk Fire and Rescue Service
Cause of concern: The service hasn’t made prevention activity a high enough priority and it isn’t adequately identifying those most at risk from fire. Recommendation: By 28 February 2022, the service should put in place plans that are designed to …
Recommendation
FRS 2021-22 CoC Recommendations: Norfolk Fire and Rescue Service
Cause of concern: The service hasn’t made prevention activity a high enough priority and it isn’t adequately identifying those most at risk from fire. Recommendation: By 28 February 2022, the service should put in place plans that are designed to …
Recommendation
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 …
Recommendation
FRS unknown CoC Recommendations: Hertfordshire Fire and Rescue Service
Cause of concern: Prevention activity isn’t a sufficiently high priority for the service. The service should implement a robust and consistent method of identifying risk and vulnerability. It should detail how it will prioritise home fire safety checks to those …
Recommendation
FRS unknown CoC Recommendations: Hertfordshire Fire and Rescue Service
Cause of concern: Prevention activity isn’t a sufficiently high priority for the service. The service should implement a robust and consistent method of identifying risk and vulnerability. It should detail how it will prioritise home fire safety checks to those …
Recommendation
FRS unknown CoC Recommendations: Hertfordshire Fire and Rescue Service
Cause of concern: Prevention activity isn’t a sufficiently high priority for the service. The service should implement a robust and consistent method of identifying risk and vulnerability. It should detail how it will prioritise home fire safety checks to those …
Recommendation
FRS unknown CoC Recommendations: Hertfordshire Fire and Rescue Service
Cause of concern: Prevention activity isn’t a sufficiently high priority for the service. The service should implement a robust and consistent method of identifying risk and vulnerability. It should detail how it will prioritise home fire safety checks to those …
Recommendation
FRS unknown CoC Recommendations: Hertfordshire Fire and Rescue Service
Cause of concern: Prevention activity isn’t a sufficiently high priority for the service. The service should implement a robust and consistent method of identifying risk and vulnerability. It should detail how it will prioritise home fire safety checks to those …
Recommendation
FRS 2021-22 CoC Recommendations: Hereford and Worcester Fire and Rescue Service
Cause of concern: Prevention activity is not a sufficiently high priority for the service and it is not adequately identifying those most at risk from fire. Recommendation: By 31 August 2021, the service should have plans in place for the …
Recommendation
FRS 2021-22 CoC Recommendations: Hereford and Worcester Fire and Rescue Service
Cause of concern: Prevention activity is not a sufficiently high priority for the service and it is not adequately identifying those most at risk from fire. Recommendation: By 31 August 2021, the service should have plans in place for the …
Recommendation
FRS 2021-22 CoC Recommendations: Hereford and Worcester Fire and Rescue Service
Cause of concern: Prevention activity is not a sufficiently high priority for the service and it is not adequately identifying those most at risk from fire. Recommendation: By 31 August 2021, the service should have plans in place for an …
Recommendation
FRS 2018-19 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: Gloucestershire Fire and Rescue Service does not have a clear protection strategy that describes how it will manage its statutory responsibilities using its risk-based inspection programme (RBIP) to identify the highest-risk premises. The service has difficulty in …
Recommendation
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 …
Recommendation
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 …
Recommendation
FRS 2018-19 CoC Recommendations: Essex County Fire and Rescue Service
Cause of concern: The service has insufficient resources to meet its risk-based inspection programme. It is currently not meeting its targets. As a result, partially-skilled operational staff are carrying out high-risk visits, although the service acknowledges these are not audits. …
Recommendation
FRS 2021-22 CoC Recommendations: Essex County Fire and Rescue Service
Cause of concern: The service has insufficient resources to meet its risk-based inspection programme. It is currently not meeting its targets. As a result, partially skilled operational staff are carrying out high-risk visits, although the service acknowledges that these are …
Recommendation
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 …
Recommendation
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 …
Recommendation
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 …
Recommendation
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 …
Recommendation
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 …
Recommendation
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 …
Recommendation
FRS 2021-22 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: The service still does not have effective systems in place to manage risk-critical information to make sure it is collected, shared and reviewed in a consistent and timely manner. Recommendation: By 31 August 2021, the service should …
Recommendation
FRS 2021-22 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: The service still does not have effective systems in place to manage risk-critical information to make sure it is collected, shared and reviewed in a consistent and timely manner. Recommendation: By 31 August 2021, review the plans …
Recommendation
FRS 2021-22 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: The service still does not have effective systems in place to manage risk-critical information to make sure it is collected, shared and reviewed in a consistent and timely manner. Recommendation: By 31 August 2021, make sure that …
Recommendation
FRS 2023-25 CoC Recommendations: Buckinghamshire Fire and Rescue Service
Cause of concern: Some improvements in prevention have been made since our last inspection. The service has revised its prevention strategy, and this is giving its prevention and response teams better direction. But the service is still not adequately identifying …
Recommendation
FRS 2023-25 CoC Recommendations: Buckinghamshire Fire and Rescue Service
Cause of concern: Some improvements in prevention have been made since our last inspection. The service has revised its prevention strategy, and this is giving its prevention and response teams better direction. But the service is still not adequately identifying …
Recommendation
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 …
Recommendation
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 …
Recommendation
FRS 2021-22 CoC Recommendations: Buckinghamshire Fire and Rescue Service
Cause of concern: Prevention activity is not a sufficiently high priority for the service, and it is not adequately identifying those most at risk from fire. Recommendation: By 30 September 2021, the service should have plans in place for:- the …
Recommendation
FRS 2021-22 CoC Recommendations: Buckinghamshire Fire and Rescue Service
Cause of concern: Prevention activity is not a sufficiently high priority for the service, and it is not adequately identifying those most at risk from fire. Recommendation: By 30 September 2021, the service should have plans in place for:- the …
Recommendation
FRS 2021-22 CoC Recommendations: Buckinghamshire Fire and Rescue Service
Cause of concern: Prevention activity is not a sufficiently high priority for the service, and it is not adequately identifying those most at risk from fire. Recommendation: By 30 September 2021, the service should have plans in place for:- an …
Recommendation
FRS 2018-19 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: Avon FRS isn’t doing enough to keep the public safe through regulation of fire safety. Its risk-based inspection programme is entirely reactive, as its inspection department doesn’t have enough staff. Recommendation: The service should make sure it …
Recommendation
IMB annual reports(18)
Elmley (2024)
HMP Elmley faces significant challenges, notably an "intolerable" fire safety risk in House Block 5 and generally deteriorating accommodation. While healthcare and equality initiatives show improvement, safety remains a concern with increased self-harm and use of force incidents, exacerbated by poor key working and inconsistent reception processes. Education attendance is low, and there's a need for more purposeful activity.
PRISON
Key concerns
Leyhill (2023)
HMP Leyhill, a Category D open prison, faces a complex transition with reduced capacity due to construction and a changing demographic towards a younger population. While safety, healthcare uptake, and education attendance are positive, significant concerns persist regarding resettlement delays for IPP prisoners due to a lack of approved premises and inefficiencies in external probation. Alarm systems, staffing levels, and the increasing presence of illicit items also require urgent attention, alongside challenges in food budgeting and healthcare screening for new arrivals.
PRISON
Key concerns
Lincoln (2023)
HMP Lincoln, a Category B prison, experienced a decrease in self-harm incidents and drug finds during the reporting period, alongside generally positive staff-prisoner relationships. However, significant concerns persist regarding the length and quality of maintenance work by Amey, and the inadequate access to specialist mental health facilities. Other key challenges include the impact of increasing operational capacity, difficulties for transient prisoners accessing education, issues with property transfers, and unsuitable infrastructure for vulnerable prisoners.
PRISON
Key concerns
Gartree (2023)
HMP Gartree maintains a calm and ordered environment with positive staff-prisoner relationships, though faces significant challenges with its ageing infrastructure and an increase in use of force incidents. While basic healthcare access is good, mental health services and purposeful activity require improvement. The Board highlights key concerns regarding building repairs, drug infiltration, fire safety, and adequate provision for vulnerable prisoners, while acknowledging efforts in staff recruitment and regime development.
PRISON
Key concerns
Highpoint (2023)
HMP Highpoint, a large Category C training and resettlement prison, reported around 1,300 prisoners during a year marked by significant increases in self-harm, violence, and assaults on staff. Key concerns included persistent issues with prisoner property management, inadequate maintenance services, and the ongoing challenge of contraband entry. Despite these, the report highlighted positive areas such as effective induction, a strong segregation unit, and robust neurodiversity support, alongside commendations for healthcare provision.
PRISON
Key concerns
Holme House (2023)
HMP Holme House, a Category C prison, experienced a challenging year ending December 2023, marked by increased violence, use of force, and significant issues with building disrepair and illicit items. While healthcare services notably improved and purposeful activity places expanded, staffing shortages impacted resettlement and Ofsted rated all five inspection areas as 'requires improvement'. The Board highlights the need for urgent attention to infrastructure, safety, and addressing the impact of a growing young adult population.
PRISON
Key concerns
Huntercombe (2023)
HMP Huntercombe, a Category C prison for foreign national men, largely maintained a full regime during 2023, with positive staff-prisoner relationships and a reduction in ACCTs. However, the Board remains significantly concerned about the influx of illicit items, persistent issues with heating, hot water, and cell window repairs, and an unsuitable healthcare building. Delays in transferring mentally unwell prisoners and ongoing property problems for those being deported are also highlighted, alongside staffing pressures in the Offender Management Unit.
PRISON
Key concerns
Garth (2023)
HMP Garth, a Category B training prison, generally provides a safe environment, though self-harm and violence incidents increased. The Board's key concerns include persistent staff shortages impacting regime stability, key worker schemes, and offender management. The prison's physical estate is in poor condition, and delays in mental health transfers for complex cases remain critical. The IMB highlights the ongoing challenges of the IPP sentence and issues with prisoner progression and property transport.
PRISON
Key concerns
Kirklevington Grange (2023)
HMP Kirklevington Grange, a Category D open prison, is considered a safe environment with positive staff-prisoner relationships and effective healthcare provision. Notable improvements in resettlement and external employment opportunities were observed. However, the Board expressed concerns over an increase in use of force incidents, an ageing estate infrastructure, and diminished chaplaincy services. Further issues include the impact of TPRS transfers on prisoner progression and persistent problems with property loss during inter-establishment transfers, as well as limited accredited vocational training opportunities.
PRISON
Key concerns
North East Midlands, Yorkshire & Humber STHF (2024)
The IMB report for North East Midlands, Yorkshire & Humber STHFs highlights varied conditions across the region's facilities, with particular focus on Swinderby RSTHF. While Swinderby benefits from positive staff-detainee relations and improved facilities, significant concerns persist regarding physical safety during building works, inadequate risk identification processes, and non-compliance with safer detention guidelines. Across all STHFs, the Board criticizes the policy on detainee medication, the unsuitability of some holding rooms, and restricted IMB access to essential documentation.
PRISON
Key concerns
Hollesley Bay (2023)
HMP/YOI Hollesley Bay generally provides a safe and humane environment, effectively handling bullying and aggression with no serious incidents in 2023. The Board commended the assimilation of PCoSO prisoners, the strong emphasis on employability, and the effective use of Release on Temporary Licence (ROTL) for resettlement. Key concerns include the Government's rejection of IPP re-sentencing, the negative impact of temporary transfer schemes on prisoner engagement, and the need for greater investment in the open estate, including property management and healthcare provision.
PRISON
Key concerns
Thorn Cross (2020)
HMP/YOI Thorn Cross is a high-performing open prison for adult males, offering a positive rehabilitative culture where prisoners generally feel safe and are treated humanely. While the prison demonstrates good healthcare provision and strong staff-prisoner relationships, key concerns include the unsatisfactory state of the OMU building, the unsuitability of new furniture, and issues surrounding prisoner transfers, particularly regarding drug status and medical needs. The Board also highlights the need for a re-evaluation of mobile phone use and the high cost of telephone calls to maintain family links.
PRISON
Key concerns
Leicester (2023)
HMP Leicester is well-led, maintaining a relatively safe environment with reduced self-harm and assaults on staff, and improved reception facilities. Despite generally good physical and mental healthcare, significant concerns persist regarding long delays for mentally ill prisoners awaiting transfer, which can result in inhumane segregation. Staffing shortages have severely impacted key working and the regime on weekends, while aging infrastructure requires substantial capital investment, particularly for the gym. Resettlement efforts are hindered by a high proportion of men released without accommodation and underdeveloped substance misuse services.
PRISON
Key concerns
Grendon (2023)
HMP Grendon, a Category B therapeutic prison, maintained its core function and safety despite an increase in self-harm and violence intelligence reports. However, the Board raised significant concerns including persistent staff shortages impacting therapy and education, an ongoing rat infestation, and an inadequate night sanitation system. Patient satisfaction with healthcare significantly declined, exacerbated by a critical lack of data, while delays in a fire safety project and the issue of men unable to move out of therapy caused further disruption.
PRISON
Key concerns
Isle of Wight (2023)
HMP Isle of Wight's population rose to 1,089 in 2023, operating at near capacity. The prison experienced a rise in deaths in custody (13) and violent incidents (191), although self-harm decreased. Key challenges included aging infrastructure, high staffing vacancies in OMU and healthcare, and inconsistent regime delivery for older prisoners, while positive developments were noted in education and integrated mental health services.
PRISON
Key concerns
Frankland (2023)
HMP Frankland, a Category A dispersal prison, operated close to its 852 capacity, maintaining a generally safe environment despite some serious assaults. The IMB noted improvements in healthcare provision, reducing a previous 'enhanced surveillance' status, and a 75% achievement rate in education. Persistent concerns include outdated CCTV, ongoing kitchen equipment breakdowns and heating issues causing lost workdays, and long-standing problems with prisoner property during transfers. The Board also highlighted challenges in mental health provision for complex cases and inadequate facilities for older and disabled prisoners.
PRISON
Key concerns
Heathrow immigration removal centre (2023)
The IMB report for Heathrow IRC (2023) highlights increasing safety concerns, including a rise in self-harm (180 incidents), assaults (131 detainee-on-detainee, 54 on staff), and drug finds (104). The Board expresses significant concerns over the detention of mentally unfit individuals, the dilapidated infrastructure, and the misuse of segregation units. While health needs are generally met, staffing shortages and delayed Rule 35 responses remain problematic. The report also notes repeated concerns about prolonged detention times and the need for improved resettlement pathways for those on bail.
IRC
Key concerns
Preston (2020)
The Board found HMP Preston to be a well-run prison with good staff-prisoner relationships, despite the challenges of its Victorian infrastructure. Key concerns include the need for capital investment in reception and visits facilities, securing the adjacent museum building for security, improving body-worn camera usage, and investigating the unexpected lack of impact of the key worker scheme on IMB applications. The prison adapted well to the initial impact of the COVID-19 pandemic.
PRISON
Key concerns
IMB individual recommendations(16)
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.
Ministry of Justice
Implemented
Thorn Cross (2020)
The fire alarm system does not meet current standards. The residential units have now had adaptations to an external door, which can be opened by the prisoners in an emergency, allowing their exit. The installation of a new system, including smoke alarms in each room, has been dragging on for some time; however, although planning meetings and site surveys are …
HMPPS
In Progress
Styal (2021)
There is a significant fire risk to prisoners who reside in the 16 houses which have not yet been refurbished at Styal. A recent survey has classed all of these buildings as red fire risk. These risks include the existence of false ceilings, and ceilings made of lath and plaster, which would require expensive and specialist repair to be brought …
Ministry of Justice
In Progress
Grendon (2022)
Improvements to the delivery schedule of the ongoing fire and safety project, as well as improved handovers of completed wings, are necessary in order to reduce disruption and return the prison to capacity (5.1).
HMPPS
North East Midlands, Yorkshire & Humber STHF (2024)
We recommend that the Contractor and Compliance Officer at Swinderby RSTHF review fire safety arrangements in light of the Board’s concerns about possible risks that have arisen during the reporting period (see sections on floor works and unlocking of fire evacuation doors).
Other
Styal (2025)
What additional resource will be made available to mitigate the serious fire safety concerns highlighted by the Board?
HMPPS
Gartree (2023)
Can the Prison Service confirm who ultimately is responsible for monitoring fire safety compliance in Gartree?
HMPPS
Grendon (2022)
Improvements to night sanitation from the fire safety project have yet to be evidenced and the Board continues to believe that the system does not meet decency and hygiene outcomes for prisoners (5.1.2).
HMPPS
Gartree (2024)
In last year’s report, the Board raised some issues about fire safety: there was no assurance that everyone knew either what a ‘general’ fire alarm sounded like or what should happen if one was heard. There have been some drills carried out in the past year and this is encouraging. Will the Board be allowed access to the report of …
HMPPS
Noted
Wakefield (2025)
The Board remains dissatisfied with the lack of progress in upgrading the physical infrastructure of the prison. We are monitoring the fire safety upgrade project, but there remains a need to focus investment in buildings that enable a productive regime. The evident lack of investment is creating frustration amongst staff and prisoners, particularly when the consequences lead to regime curtailment. …
HMPPS
In Progress
Thorn Cross (2020)
Following the sudden removal of chairs throughout the prison, replacement ones have now arrived. They are totally unsuitable. They look unattractive, easily tip up when you sit on the edge, and are uncomfortable. Prisoners have refused to use them, leaving many without a chair in their rooms. We are not convinced that a more suitable chair, at a reasonable cost, …
HMPPS
In Progress
Grendon (2020)
The Board appreciates that the current fire safety work includes some upgrade to the sanitation system software but believes that this work is unlikely to address the decency issues raised (see paragraphs 5.1.4 and 5.1.9).
HMPPS
In Progress
East Sutton Park (2022)
To review the fire contingency plan, as the Board considers that the new system needs to be carefully monitored as to its effectiveness at reaching all areas of the prison in a prompt manner.
Governor / Director
Grendon (2023)
The Board recommends that the Prison Service indicates when the delays in the delivery schedule of the ongoing fire and safety project will be permanently resolved.
HMPPS
In Progress
Gartree (2023)
Will the Minister confirm, again, that the necessary funding will be made available to Gartree to address the unacceptable state of the showers? In the response to the IMB’s 2021-2022 annual report, the Minister advised that ‘shower upgrades have been incorporated into the fire safety improvement programme…’. The building work on B wing took much longer than advised and there …
Ministry of Justice
Styal (2025)
Given the restrictions and huge costs of repairing Victorian buildings and refurbishing them to meet decency and fire safety standards, is any consideration being given to the total replacement of the existing prison buildings, and their replacement with accommodation and facilities more suited to the 21st century?
Ministry of Justice
Implemented
National patient safety alerts(1)
Health investigations(2)
Independent investigation: Prodip Debnath, Mile End (2010) — Rec Fourteen
It is recommended that the Trust liaise with their designated fire safety officers and estates department to undertake an environmental risk assessment in order to ascertain whether it would be desirable or feasible to alter the opening mechanisms of the bedroom doors on ward A, and to provide the Trust …
london
Independent investigation into the care and treatment of Mr MC … — Rec 6
The Trust should ensure that, for forensic patients, any specific risk assessment (eg, fire setting) should be integrated with generic risk assessments and discharge plans.
south_west
Scottish Fatal Accident Inquiries(4)
James Fraser and Daniel Heron
In terms of section 6(1)(e) of the 1976 Act that consideration should be given to requiring houses in multiple occupation, as legally defined, to be fitted with hard-wired smoke detector/alarm systems. In terms of section 6(1)(e) of the 1976 Act that consideration should be given to requiring all rooms adjoining potential escape routes in houses in multiple occupation (as legally …
Mar 1999
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 of a …
Dec 2008
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 by the …
Jan 2023
Other
6 recs
Thomas Oliver Hill
The Sheriff, in terms of section 26(1)(b) of the Act, and having regard to the matters mentioned in section 26(4) of the Act, Recommends that: [1] Local authorities in Scotland should consider making it a condition of any licence issued in terms of The Civic Government (Scotland) Act 1982 (Licensing of Short-term Lets) Order 2022 that licence holders provide specific …
Sep 2023
Detention investigations(7)
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 52
fire drills be held at Yarl’s Wood at least monthly and that the requirement for detainees to leave the building be rigorously enforced.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 23
the fire safety adviser and the Crown Property Inspection Group take early steps to establish provenance on receipt of any request for advice and that they reserve their position until the matter has been resolved.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 16
GSL reviews its fire signage at all its centres and carries out regular management checks to ensure all fire safety measures are complied with.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 15
GSL reviews its fire contingency plans to ensure they are appropriate and offer adequate protection for detainees and staff.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 53
a member of the senior management team at Yarl’s Wood be given specific responsibility for fire safety.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 24
I do not think the case is made out for the installation of sprinklers in all removal centres, no matter what their size, function, or construction. It seems to me that each case should be judged on its merits, and this is what I recommend.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 10
the use of remotely-operated locks for zone gates be considered in all future removal centre designs, taking account of any fire safety requirements.
Immigration Detention
Independent reviews(19)
Hackitt Review — Rec 4.1
a. The dutyholder for a HRRB should have a statutory duty to proactively provide residents with a set of information that supports residents to understand the layers of protection in place to keep their building safe. b. The government should consider applying this requirement to other multi-occupancy residential buildings.
Building Safety
Accepted
Hackitt Review — Rec 3.7
a. For HRRBs, Environmental Health Officers should raise any fire and structural safety concerns to the JCA. b. For other multi-occupancy residential buildings, local authorities and fire and rescue authorities should work more closely to ensure that the fire safety of the whole building is assessed and regulated effectively.
Building Safety
Accepted
Hackitt Review — Rec 3.5
a. For HRRBs, residents should have clearer obligations in relation to maintaining safety of flats and should cooperate with the dutyholder (or building safety manager) to the extent necessary to enable them to fulfil their duty to keep the building safe for all those living there. b. The dutyholder should …
Building Safety
Accepted
Hackitt Review — Rec 3.4
a. The dutyholder for a HRRB should demonstrate that the fire risk assessment for the whole building has been undertaken by someone with relevant skills, knowledge and experience and reviewed regularly (dependent on risk and as agreed with the regulator) so as to keep it up to date and particularly …
Building Safety
Accepted
Hackitt Review — Rec 3.3
The dutyholder for a HRRB should proactively demonstrate to the JCA through a safety case at regular intervals (as determined by level of risk) that they are discharging their responsibilities. The safety case must identify the hazards and risks, describe how risks are controlled, and describe the safety management system …
Building Safety
Accepted
Hackitt Review — Rec 2.14
Where a HRRB has not yet had its first safety case review and seeks to carry out refurbishment work then this should trigger a full safety case review as set out in paragraphs 2.58-2.59. Once the safety case review cycle is established then further major refurbishments may also bring forward …
Building Safety
Accepted
Hackitt Review — Rec 2.5
The LPA should be required in law to undertake a consultation with the JCA where it identifies that a building is a HRRB. This process should also apply where planning permission for another building in the near vicinity is sought (where such a building might impact on fire service access …
Building Safety
Accepted
Hackitt Review — Rec 2.3
Government should make the creation, maintenance and handover of relevant information an integral part of the legal responsibilities on Clients, Principal Designers and Principal Contractors undertaking building work on HRRBs. The four information products (the digital record, the Fire and Emergency File, Full Plans and Construction Control Plan) represent a …
Building Safety
Accepted
Hackitt Review — Rec 3.8
For HRRBs there should be robust sanctions and strong incentives in place to drive compliance by dutyholders during occupation. The JCA should use a staged approach comprising education, statutory notices, fines and ultimately criminal sanctions.
Building Safety
Accepted
Hackitt Review — Rec 3.2
Government should allocate clear responsibilities to dutyholders of HRRBs to: a. take such safety precautions as may reasonably be required to ensure building safety risk is reduced so far as is reasonably practicable; b. ensure that information management systems are in place in order to maintain relevant documentation and compile …
Building Safety
Accepted
Hackitt Review — Rec 3.1
a. Government should specify that responsibility for the safety of all parts of a HRRB must be held by a clear, senior dutyholder which should be the building owner or superior landlord. b. The JCA and residents must be kept notified of the name and UK-based contact information of the …
Building Safety
Accepted
Hackitt Review — Rec 2.12
a. As part of the establishment of the JCA, the fire and rescue authorities need to be engaged in a more consistent manner with a robust dispute resolution mechanism established for use by the organisations within it (as per paragraph 2.46). b. Comparable processes should also be adopted for other …
Building Safety
Accepted
Hackitt Review — Rec 2.9
a. there should be a clearer, statutory change control process that places requirements on the relevant dutyholder to notify the regulators of significant changes post-Full Plans sign-off. Within that context, two types of changes should be defined – ‘major’ and ‘minor’. • ‘Major’ changes would be a limited list of …
Building Safety
Accepted
Hackitt Review — Rec 2.8
Government should consider also applying Gateway Points 2 and 3 to other multi‑occupancy residential buildings and to institutional residential buildings.
Building Safety
Accepted
Hackitt Review — Rec 2.7
Government should ensure that: a. the JCA undertakes a thorough test of the dutyholders’ as-built construction of HRRBs, supported by clear documentary evidence from the Principal Contractor that the design intent has been delivered as proposed (and any changes are documented and justifiable) and that handover of key golden thread …
Building Safety
Accepted
Hackitt Review — Rec 2.6
Government should ensure that there is thorough assessment by the JCA of detailed design plans for HRRBs and sufficient assurance that dutyholders are in place and relevant responsibilities are being met in order to give permission for building work to legally commence. This should be in line with paragraphs 2.29-2.32. …
Building Safety
Accepted
Hackitt Review — Rec 2.4
Government should consider applying the key roles and responsibilities and information product recommendations to other multi‑occupancy residential buildings and to institutional residential buildings whilst bearing in mind necessary adjustments to keep the requirements proportionate.
Building Safety
Accepted
Hackitt Review — Rec 1.2
The government should set up a ‘Joint Competent Authority’. This should comprise Local Authority Building Standards, fire and rescue authorities and the Health and Safety Executive, working together to maximise the focus on building safety within HRRBs across their entire life cycle. The optimum model for ensuring effective joint working …
Building Safety
Accepted
Hackitt Review — Rec 1.1
The new regulatory framework should apply to residential properties which are 10 or more storeys high in the first instance. New HRRBs should be identified by the Local Planning Authority and notified to the regulator. Existing buildings in scope should be identified through other means, learning from the MHCLG Building …
Building Safety
Accepted
LGO / SPSO decisions(66)
20-013-206 — London Borough of Bromley
Summary: Mr X complained the Council failure to address concerns about his neighbour’s development. He said it did not comply with building regulations or its planning permission and created a potential risk of fire and water damage to his property. We do not find the Council was at fault because …
LGO (Local Government & …
Planning
Not Upheld
Jan 2022
21-018-962 — Milton Keynes Council
Summary: We cannot investigate this complaint that the the Council delayed considering, then subsequently refused the complainants request for an External Wall System Fire Review certificate. This is because we have no jurisdiction to consider complaints from leaseholder about the actions of the Council as freeholders.
LGO (Local Government & …
Planning
Apr 2022
22-002-812 — Derbyshire Fire & Rescue Service
Summary: We will not investigate this complaint that about a prohibition notice issued by the Fire Authority in 2015 and about a data protection breach. This is because the prohibition notice was issued too long ago and I see no good reason why a complaint could not have been made …
LGO (Local Government & …
Environment And Regulation
Jun 2022
23-017-684 — West Northamptonshire Council
Summary: We will not investigate this complaint about the Council’s delay in discharging planning conditions and progressing a section 106 agreement. Also, the complainant says the Council refused to meet him and discuss safety issues after a building fire. We cannot achieve the outcome the complainant is seeking. We cannot …
LGO (Local Government & …
Environment And Regulation
Mar 2024
24-023-061 — London Fire Commissioner
Summary: We will not investigate this complaint about the outcome of the Fire Service’s risk assessment. There is not enough evidence of fault to justify our involvement.
LGO (Local Government & …
Other Categories
May 2025
25-002-325 — London Fire Commissioner
Summary: We will not investigate this complaint about the recording of a fire by the Authority. This is because
LGO (Local Government & …
Other Categories
Jun 2025
24-010-970 — Cumbria Fire & Rescue Service
Summary: We will not investigate this complaint about the Authority’s response to a planning application for a commercial development. There is not enough evidence of fault and there is no significant injustice.
LGO (Local Government & …
Other Categories
Nov 2024
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.
LGO (Local Government & …
Other Categories
Dec 2024
25-011-781 — Bedfordshire & Luton Fire & Rescue Service
Summary: We will not investigate this complaint about the advice given to the Responsible Person for fire safety for the building where Mr X lives. We have not seen enough evidence of fault in the Fire Service’s actions. Also, we cannot achieve the outcome Mr X is seeking.
LGO (Local Government & …
Other Categories
Jan 2026
25-023-545 — London Fire Commissioner
Summary: We will not investigate this complaint about the London Fire Brigade’s decision to enter Ms X’s home without her permission. There is not enough evidence of fault to justify an investigation. We also cannot add to the complaint investigation or the responses the Authority sent to Ms X.
LGO (Local Government & …
Other Categories
Feb 2026
22-004-920 — Leicester City Council
Summary: We will not exercise discretion to investigate this complaint about the Council charging Mrs X for the replacement of a fire door during her Right to Buy application process in 2017. This complaint was received outside the normal 12-month period for investigating complaints. There is no evidence to suggest …
LGO (Local Government & …
Housing
Aug 2022
21-019-039 — London Borough of Redbridge
Summary: There is no fault in how the Council dealt with Mr K’s report that his housing association had failed to do works to stop condensation build up interfering with his lighting and smoke detectors.
LGO (Local Government & …
Housing
Not Upheld
Aug 2022
22-009-220 — Sedgemoor District Council
Summary: We cannot not investigate this complaint about the Council’s decision on the level of fire detection system Mr X is required to install in his HMO (House in Multiple Occupation) property. This is because Mr X used appeal rights to the Tribunal which places the complaint outside our jurisdiction.
LGO (Local Government & …
Housing
Oct 2022
24-022-586 — Cleveland Fire Brigade
Summary: We will not investigate this complaint about Authority’s response to and actions at a fire. There is no significant personal injustice, and we cannot achieve the outcome the complainant is looking for.
LGO (Local Government & …
Other Categories
Jun 2025
25-001-114 — Chesterfield Borough Council
Summary: We will not investigate Mr X’s complaint about a penalty charge notice sent by the Council for failing to have a working smoke alarm in a rented property that he owns. This is because the complaint is late.
LGO (Local Government & …
Housing
Jun 2025
24-019-366 — Somerset Council
Summary: Mrs B complained on behalf of the residents’ association that the Council failed to ensure the caravan site they live on complies with the site licence and legal requirements. The Council initially dealt with possible breaches of the licence effectively. However, it has failed to determine whether the Electrical …
LGO (Local Government & …
Environment And Regulation
Upheld
Sep 2025
24-010-464 — Gloucestershire County Council
Summary: We will not investigate this complaint about the authority’s failure to take action over a complaint about domestic fire safety. There is insufficient evidence of fault which would warrant an investigation.
LGO (Local Government & …
Environment And Regulation
Nov 2024
24-015-640 — Kirklees Metropolitan Borough Council
Summary: We will not investigate this complaint about how the Council dealt with a building control matter. This is because it is unlikely we could achieve a worthwhile outcome for the complainant.
LGO (Local Government & …
Planning
Dec 2024
25-005-008 — London Fire Commissioner
Summary: There was no fault in the way London Fire Brigade considered evidence submitted by the complainant, that the fire risk assessment for his building was flawed, or in its decision no further action was required. We have therefore completed our investigation.
LGO (Local Government & …
Other Categories
Not Upheld
Dec 2025
25-012-986 — Basingstoke & Deane Borough Council
Summary: We will not investigate this complaint about the Council’s consideration of Ms X’s reports of building control and noise concerns at her neighbour’s property. Her complaints are too late, and we have seen no reason why she could not have complained to us much sooner. Also, I have not …
LGO (Local Government & …
Planning
Jan 2026
21-014-391 — Northumberland County Council
Summary: We will not investigate Mr X’s complaint about the Council’s decision not to take action against the developer of his property in relation to a retaining wall he believes is dangerous. This is because there is no evidence of fault by the Council.
LGO (Local Government & …
Planning
Jan 2022
22-007-351 — Westminster City Council
Summary: We will not investigate Mr X’s complaint about the Council’s charges for signing off his installation of a fire-suppressant system. This is because there is not enough evidence of fault by the Council causing Mr X significant injustice.
LGO (Local Government & …
Planning
Sep 2022
22-010-976 — Allerdale Borough Council
Summary: We will not investigate Mr X’s complaint about the Council’s administration of a building control matter. Mr X’s claimed injustice stems from the Council’s decisions on the case, which we have previously investigated, and we cannot achieve the outcome Mr X wants. The Information Commissioner is better placed to …
LGO (Local Government & …
Planning
Dec 2022
24-008-779 — Colchester City Council
Summary: We will not investigate this complaint about the Council testing its fire evacuation procedures. There is no remaining unremedied injustice because of the actions the Council has already taken and in any case, we cannot award compensation for personal injury.
LGO (Local Government & …
Other Categories
Oct 2024
24-010-278 — Merseyside Fire & Rescue Service
Summary: We will not investigate this complaint about Merseyside Fire and Rescue Service’s involvement in a fire risk assessment. The Service is not responsible for some of the actions Mr X complains about. There is not enough evidence of fault in the Service’s actions to justify investigation.
LGO (Local Government & …
Other Categories
Apr 2025
24-022-887 — London Fire Commissioner
Summary: We will not investigate Mr X’s complaint about damage caused to his home following two visits from London Fire Brigade. Part of the complaint is late. It is reasonable for him to pursue a compensation claim for damage to his property through the courts and an investigation would not …
LGO (Local Government & …
Environment And Regulation
Jun 2025
24-008-606 — South Yorkshire Fire & Rescue Service
Summary: We will not investigate this complaint about the Fire Service's findings on the cause of a house fire. There is not enough evidence of fault to justify our involvement.
LGO (Local Government & …
Other Categories
Oct 2024
24-009-075 — Hampshire County Council
Summary: We will not investigate this complaint about the Council’s handling of various issues related to the proximity of a school close to Ms X’s home. This is because an investigation is unlikely to add to that already carried out by the Council or lead to a different outcome.
LGO (Local Government & …
Planning
Dec 2024
24-014-196 — Braintree District Council
Summary: We will not investigate Mr X’s complaint about how the Council dealt with his complaint or applied its Development Management Enforcement Policy. It is reasonable for Mr X to use his right of appeal to the High Court.
LGO (Local Government & …
Planning
Dec 2024
25-012-211 — Rother District Council
Summary: We will not investigate Ms X’s complaint about the management of a holiday caravan site. There is insufficient evidence of fault by the Council to justify investigation.
LGO (Local Government & …
Environment And Regulation
Feb 2026
25-012-545 — South Norfolk District Council
Summary: We will not investigate this complaint about the Council approving building works which the complainant says are defective. It is reasonable to expect the complainant to have complained to us again sooner, and it is unlikely an investigation would achieve a worthwhile outcome for them.
LGO (Local Government & …
Planning
Jan 2026
PSOW-202307826 — Charter Housing Association (Part of the Pobl Group)
Ms X raised a formal complaint concerning damp and mould to Charter Housing Association (Part of the Pobl Group) in November 2023. She complained that she has not received its response. The Ombudsman found that the Association is still actively investigating her concerns and awaiting information but failed to update …
PSOW (Public Services Om…
Housing
Jan 2024
21-009-365 — London Borough of Newham
Summary: We will not investigate this complaint about the Council’s response to a complaint about delay in providing information. This is because the response has not caused so significant an injustice as to warrant the Ombudsman’s intervention
LGO (Local Government & …
Planning
Apr 2022
23-019-400 — Brighton & Hove City Council
Summary: Mr X complained the Council failed to properly investigate and take appropriate action in relation to reports of disrepair and safety concerns at his privately rented property. We found there is no evidence of fault in the way the Council investigated or responded to reports of disrepair at Mr …
LGO (Local Government & …
Housing
Not Upheld
Sep 2024
25-001-388 — North Somerset Council
Summary: We will not investigate this complaint about the Council’s refusal to reimburse the complainant’s legal costs. This is because it is reasonable to expect Mr Y to take the matter to court who are better placed to consider the complaint.
LGO (Local Government & …
Planning
Jul 2025
25-002-370 — Leicester City Council
Summary: We will not investigate this complaint about Mr X’s complaint about the building regulations fees charged by the Council and the service provided. We have not seen enough evidence of fault in the Council’s actions. Nor do we consider the complainant has suffered a significant personal injustice which warrants …
LGO (Local Government & …
Planning
Jul 2025
25-006-339 — City of Bradford Metropolitan District Council
Summary: We will not investigate this complaint about how the Council dealt with a building control matter. This is because it is unlikely we could achieve a worthwhile outcome for the complainant.
LGO (Local Government & …
Planning
Aug 2025
24-012-397 — East Cambridgeshire District Council
Summary: Mr X complained the Council failed to take enforcement action against a developer after installing defective drainage at his home, and failed to pursue the developer for making false representations. He also said the Council signed off the drainage without completing proper checks. We found no fault in the …
LGO (Local Government & …
Planning
Not Upheld
Aug 2025
25-010-247 — Humberside Fire Authority
Summary: We will not investigate this complaint about the Authority’s position relating to public events and data collection. There is no evidence the Authority’s actions has caused X a significant injustice and we cannot achieve the outcome they seek.
LGO (Local Government & …
Other Categories
Sep 2025
25-009-960 — London Fire Commissioner
Summary: We will not investigate Ms X’s complaint about forced entry to her home by the London Fire Brigade. It is reasonable to expect Ms X to take court action for compensation damage to her property. It is unlikely investigation by us would reach a clearer view or achieve significantly …
LGO (Local Government & …
Other Categories
Sep 2025
25-006-678 — Solihull Metropolitan Borough Council
Summary: We will not investigate Miss X’s complaint about how the Council carried out building control inspections. This is because we do not start an investigation where there is not enough evidence of fault or when an investigation is unlikely to lead to a different outcome.
LGO (Local Government & …
Planning
Sep 2025
24-022-942 — Maidstone Borough Council
Summary: We found fault by the Council on Mr Y’s complaint about it failing to take prompt action against the owner of the building his rented flat was in which suffered serious damp and mould from leaks. It failed to carry out an assessment under the Housing Health and Safety …
LGO (Local Government & …
Housing
Upheld
Nov 2025
24-007-637 — Manchester City Council
Summary: We will not investigate this complaint about the Council’s inspection of Mr X’s new roof by its Building Control Service. This is because we are unlikely to find evidence of fault by the Council sufficient to warrant an investigation.
LGO (Local Government & …
Planning
Oct 2024
24-012-156 — London Fire Commissioner
Summary: We will not investigate this complaint about the actions of the Authority at an incident where it damaged Mr X’s property. We cannot achieve the outcome Mr X wants.
LGO (Local Government & …
Other Categories
Oct 2024
24-011-100 — Devon & Somerset Fire & Rescue Service
Summary: We will not investigate this complaint about the Authority’s decision on how it responded to fire safety concerns Mrs X raised with it. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate. There is no significant …
LGO (Local Government & …
Other Categories
Oct 2024
24-011-800 — Royal Borough of Greenwich
Summary: We will not investigate Mr X’s complaint about the Council’s failure to take enforcement action regarding several metal structures he believes are unsafe and may breach the Building Regulations. This is because the issue does not cause Mr X significant enough injustice to warrant investigation. As the structures have …
LGO (Local Government & …
Planning
Nov 2024
201300467 — Albyn Housing Society Ltd
Mrs C lives in a house that had electric night storage heaters, using an economy meter with a reduced tariff. Following public meetings with their tenants, the housing association decided to implement a programme of external wall insulation and replace night storage heating with an air source heat pump system. …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Jan 2014
201203796 — Prospect Community Housing
Mr C raised concerns about the way in which the association dealt with a leak from his flat into his downstairs neighbour's property. He said they failed to identify the real cause of the leak as a broken pipe and unreasonably issued him with an invoice for the repairs. In …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Jan 2014
25-015-454 — London Borough of Hounslow
Summary: We will not investigate this complaint about the Council’s response after Miss X reported disrepair and hazards at the property she privately rents. This is because it is unlikely we will find fault by the Council and we cannot achieve the outcome she seeks.
LGO (Local Government & …
Housing
Dec 2025
201900196 — South Lanarkshire Council
A number of years ago, Mr C bought a new build property from a housing developer. Mr C had work done to his property and the structural steel beams were exposed. Mr C was concerned that they did not have adequate fire protection and that the construction differed from the …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Jul 2020
Domestic Homicide Reviews(4)
Norfolk — recommendation 9
All statutory, voluntary, or private services’ practitioners and carers whose role includes home safety advice and where a service user has or are intending to install privately purchased wi-fi enabled fire alarms, should strongly advise that at least two devices should be linked to the alarms to ensure back-up if …
All statutory, voluntary, or private services’ …
Norfolk — recommendation 3
Where fire hazards are identified during home visits by clinicians and/or practitioners, the Fire Service should be contacted to offer a home safety assessment and guidance to the service user.
Norfolk County Council | Norfolk Community …
Norfolk County Council
Torfaen — recommendation 2
Future revisions of the Domestic Abuse, Stalking and Honour Based Violence Risk checklist (DASH) are revised to include the threat of arson or history of fire setting..
Home Office
Home Office
Norfolk — recommendation 8
Websites including the Norfolk County Council assisted technology site, the Fire & Rescue Service home safety site, and other county websites which give home safety advice, to insert a prominently displayed message, strongly advising that at least two people’s phones, tablets or similar devices should be linked to wi-fi enabled …
Norfolk County Council | Norfolk Fire …
Norfolk County Council
CQC enforcement actions(2)
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission (CQC) took enforcement action, serving Greater Manchester Mental Health NHS Foundation Trust with two Section 29A warning notices. One notice related to ligature and fire risks, and the other to staffing and governance, requiring significant improvements …
Nov 2022
Warning Notice: Gloucestershire Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) issued a warning notice to Gloucestershire Hospitals NHS Foundation Trust following an unannounced inspection of urgent and emergency services at Gloucestershire Royal Hospital in December. The inspection was prompted by concerns from people using the …
Gloucestershire Royal Hospital
May 2024