Vulnerable people fire risk
Failure of social services and housing providers to proactively assess fire risks, identify vulnerable individuals, and implement preventative measures.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
85match
Gabrielle Steel
The coroner noted insufficient follow-up by an occupational therapist and social worker regarding a fire safety visit's outcome. There was also a lack of communication from the London Fire Brigade, which shared findings only with the vulnerable individual and did not provide the written risk assessment to her carers or family, preventing a risk management plan from being...
Matched on
terms: fire, vulnerable
PFD report
77match
Betty Grace Payne
The coroner identified a need for improved information sharing with the Fire Service about vulnerable individuals at risk of fire. Where information cannot be shared, local authority staff could receive training to conduct home fire safety checks.
Matched on
terms: fire, vulnerable
PFD report
75match
Brian MaClean
The coroner noted a lack of proactive risk assessment and understanding by Social Services regarding the deceased's fire risks. Concerns were raised about the absence of processes for fire risk identification, referrals to the fire service, and installation of appropriate fire suppression systems and assistive technology in properties by the housing provider.
Matched on
terms: fire
PFD report
73match
Emma Waring
The coroner noted the absence of compulsory inclusion of automatic water suppression systems (domestic sprinklers) in the design and building phases of residential properties, particularly those for vulnerable individuals, to enhance fire safety.
Matched on
terms: fire, vulnerable
PFD report
73match
Reginald Cauthery
The telecare service was not reviewed despite a patient's increased fire risk and deteriorating mobility. A smoke alarm not connected to the telecare system delayed emergency services for a vulnerable person living alone.
Matched on
terms: fire, vulnerable
Inquiry recommendation
72match
P2-10 - Require fire safety strategy from registered fire engineer at Gateway 2
That it be made a statutory requirement that a fire safety strategy produced by a registered fire engineer to be submitted with building control applications (at Gateway 2) for the construction or refurbishment of any higher-risk building and for it to be reviewed and re-submitted at the stage of completion (Gateway 3). Such a strategy must take into...
Matched on
terms: fire, people, vulnerable
PFD report
69match
Alfred Hodges
Concerns relate to vulnerable Telecare users in Conwy County lacking standard interlinked smoke alarms, with insufficient interim provisions during a two-year roll-out. The council also did not make the deceased aware of available free home fire safety checks.
Matched on
terms: fire, vulnerable
PFD report
69match
Sylvia Griffiths
The coroner identified a need for improved communication regarding fire/smoke alarms designed for people with dementia and greater collaboration with support groups to promote their use.
Matched on
terms: fire, people
PFD report
65match
William Thompson
A high-risk service user lacked a smoke detector in their bedroom, and social workers had not considered this despite known fire risks and previous fire brigade call-outs.
Matched on
terms: fire
PFD report
65match
Neil Barre
The coroner noted that Staffordshire Fire and Rescue Service might benefit from awareness when domiciliary care recipients do not use provided special fire safety equipment, suggesting improved communication with care providers.
Matched on
terms: fire
PFD report
65match
Brian Harfield
The coroner highlights the lack of compulsory sprinkler or fire safety provisions for individuals in extra care facilities or retirement housing receiving care at home. This group's declining health and mobility increase their fire risk, a gap not addressed by current consultations.
Matched on
terms: fire
Committee recommendation
65match
#11 - Sixteenth Report - Progress in remediating dangerous cladding
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 evacuate exacerbate the risks presented by dangerous cladding.38 While acknowledging that the presence of elderly or vulnerable residents...
Matched on
terms: fire, vulnerable
PFD report
61match
Vera Lillian Steel
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.
Matched on
terms: fire
PFD report
61match
Julie Ann Camm
The coroner noted the absence of smoke detectors in the property and that fire safety check procedures were not in place. The report recommends the property owner inspect all housing stock to ensure hard-wired or battery-operated smoke detectors are fitted.
Matched on
terms: fire
PFD report
61match
Ian Leak
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.
Matched on
terms: fire
PFD report
61match
Kevin Freely
The coroner noted insufficient awareness among patients and care organisations regarding the fire hazard of paraffin-based skin products combined with smoking and airflow mattresses. Concerns were also raised about the lack of risk assessments and an operational smoke detector.
Matched on
terms: fire
PFD report
61match
Christopher Hart
The coroner noted that Johnnie Johnson Housing imposes no conditions on tenants regarding furniture fire safety standards and is not undertaking a formal review into introducing sprinkler systems into its properties.
Matched on
terms: fire
PFD report
61match
Christopher Evans
The coroner identified a deficiency in the regulatory framework for HMOs accommodating vulnerable persons, which means there is no requirement to assess and manage scalding risks or for regulatory oversight by bodies like CQC or HSE.
Matched on
terms: vulnerable
PFD report
61match
Liam Allan
Concerns were raised regarding inadequate lighting and inconsistent reflective markings on riverside buoyancy aids, hindering their rapid deployment. Additionally, the communication process between the Metropolitan Police Service and the London Fire Brigade relies on a slower telephone system instead of faster electronic transfer, potentially delaying emergency response.
Matched on
terms: fire
Committee recommendation
61match
#12 - Sixteenth Report - Progress in remediating dangerous cladding
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 That 2% are above four storeys would still equate to around 800 care homes, sheltered homes, and hospitals...
Matched on
terms: vulnerable
PFD report
57match
Sidney Harvey
The coroner raised concerns about the presence of non-safety glass doors in rented properties where elderly people or children are occupants, and the lack of a system for replacing or making these doors safe.
Matched on
terms: people
PFD report
57match
John Hills
The coroner raises concerns about the lack of fire hazard warnings on paraffin-based emollient creams like Cetraben and insufficient communication of fire risks to patients. Existing guidance may not adequately cover proprietary creams with lower paraffin content.
Matched on
terms: fire
PFD report
57match
Brian Bicat
The coroner identified inadequate fire hazard warnings on packaging for paraffin-based emollients, insufficient awareness among healthcare professionals, and a lack of consistent advice and data collection regarding their safe use.
Matched on
terms: fire
PFD report
57match
Mihaela Lazar
The coroner identified inadequate fire safety provisions in maisonettes, noting a lack of early fire detection, warning systems, and protected escape routes from upper floors. Many older properties have not been upgraded to current standards, posing significant risk.
Matched on
terms: fire
PFD report
57match
Tony Goodridge
The coroner noted that the property lacked a smoke alarm and the London Fire Brigade experienced difficulties accessing the premises due to parked vehicles.
Matched on
terms: fire
PFD report
57match
Riley Holt, Keegan Unitt, Tilly-Rose Unitt and Olly Unitt
The coroner noted that children under 16, particularly boys, may not respond to conventional smoke alarms. This indicates a need for fire suppression systems to be legally required in all new-build properties in England.
Matched on
terms: fire
PFD report
57match
Henry Boddy
The coroner noted a gap in enforcement powers to address fire risks in residential properties, particularly those arising from hoarding behaviour.
Matched on
terms: fire
PFD report
57match
James Golds
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.
Matched on
terms: fire
PFD report
57match
Saima Usman
The coroner noted that privately rented accommodation in the London Borough of Wandsworth lacks a registered landlord scheme, meaning smoke and carbon monoxide detectors are not required. This absence increases the risk of death from fire or CO exposure for residents.
Matched on
terms: fire
PFD report
57match
Paul Keating
The coroner noted the local authority lacked statutory power to install sprinkler systems in private dwellings without occupant consent. This meant Mr. Keating's flat was the only one not connected to the tower block's fire safety system.
Matched on
terms: fire
Scottish FAI
53match
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...
Matched on
terms: fire
Inquiry recommendation
51match
P1-28 - National guidelines for high-rise evacuations
The government develop national guidelines for carrying out partial or total evacuations of high-rise residential buildings, such guidelines to include the means of protecting fire exit routes and procedures for evacuating persons who are unable to use the stairs in an emergency, or who may require assistance (such as disabled people, older people and young children).
Matched on
terms: fire, people
PFD report
49match
Jacqueline Joseph
The coroner noted that a housing association property, managed by Squared (Luton Community Housing Ltd), had two incorrectly installed battery-operated smoke alarms.
Matched on
classifier match
Inquiry recommendation
48match
P1-36 - Require understandable fire safety instructions
The owner and manager of every residential building containing separate dwellings (whether or not it is a high-rise building) be required by law to provide fire safety instructions (including instructions for evacuation) in a form that the occupants of the building can reasonably be expected to understand, taking into account the nature of the building and their knowledge...
Matched on
terms: fire
LGO / SPSO decision
46match
PSOW-202405250 - Trivallis
Mrs C complained about whether Trivallis (“the Association”) responded appropriately to reports of damp and mould made by her between November 2023 and the present time. The investigation found that the Association did not always respond appropriately to reports of damp and mould. Reports of issues in Mrs C’s home were not always acted on promptly or line...
Matched on
terms: people, vulnerable
PFD report
45match
Anne Fowler
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.
Matched on
classifier match
PFD report
45match
Sadie Peters, Joseph Peters and George Peters
The coroner raises concerns about insufficient awareness among caravan users and residents regarding the importance of fitting and maintaining smoke detectors in mobile and static caravans.
Matched on
classifier match
PFD report
45match
Sharon Soares
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.
Matched on
classifier match
PFD report
45match
Jac Davies
The coroner identified that landlords in Wales are not under a legal duty to install working smoke alarms in rented properties, contrasting with the legal requirements in England.
Matched on
classifier match
PFD report
45match
Daphne Holloway and Ivy Spriggs
Sprinkler systems are not a mandatory requirement for care homes with immobile occupants, and such homes are not deemed 'Higher Risk Buildings' unless they meet specific height or storey criteria, despite occupant vulnerability.
Matched on
classifier match
IMB recommendation
39match
Bure (2025)
The Governor should ensure adequate heating is provided in Residential Unit 7, especially for elderly and vulnerable prisoners, and resolve the ongoing issue with the heating system.
Matched on
terms: vulnerable
LGO / SPSO decision
39match
22-004-363 - London Borough of Newham
Summary: Mr Y complained about the way the Council dealt with his request that it recall two outstanding penalty charge notice debts from its enforcement agents because he is a vulnerable person. We found fault in how the Council considered his request. But this fault did not cause Mr Y an injustice and so we have completed our...
Matched on
terms: vulnerable
IMB recommendation
35match
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...
Matched on
terms: fire
Inquiry recommendation
32match
P1-33 - Require PEEP information in premises information box
The owner and manager of every high-rise residential building be required by law to include up-to-date information about persons with reduced mobility and their associated PEEPs in the premises information box.
Matched on
classifier match
Inquiry recommendation
32match
P1-32 - Require personal emergency evacuation plans (PEEPs)
The owner and manager of every high-rise residential building be required by law to prepare personal emergency evacuation plans (PEEPs) for all residents whose ability to self-evacuate may be compromised (such as persons with reduced mobility or cognition).
Matched on
classifier match
Committee recommendation
31match
#16 - Fifth report: Pre-legislative scrutiny of the Building Safety Bill
We recommend that the Government specify in the Bill itself by way of a requirement to “have regard” the factors that must be considered in the future when the scope of the regime is expanded and that the ability of residents to evacuate the building be the principal factor. We also recommend that any requirement to have regard...
Matched on
classifier match
Committee recommendation
31match
#15 - Fifth report: Pre-legislative scrutiny of the Building Safety Bill
On balance, we consider the initial definition of “higher-risk building” proposed by the Government to be reasonable and practical, though we agree with the evidence calling for the scope to be widened in the future to include a great number of risk 60 Pre-legislative scrutiny of the Building Safety Bill factors. In particular, the scope should take account...
Matched on
classifier match
CQC action
31match
Homelea Residential Care Home
The provider told us they would be implementing PEEPS in the near future.
Matched on
classifier match
LGO / SPSO decision
30match
PSOW-202407682 - Newport City Homes
Miss A complained that Newport City Homes (“the Housing Association”) failed to address issues including vermin, damp and heating at her home, which had been ongoing since September 2023. Windows would not lock and repairs to pipework, undertaken following flooding at the property, were not completed properly. Miss A was given conflicting information about who was responsible for...
Matched on
classifier match
PPO recommendation
30match
The Governor
The Governor should ensure that before prisoners are located on B Wing, they are appropriately assessed to ensure they are vulnerable prisoners or are suitable to be housed with vulnerable prisoners.
Matched on
terms: vulnerable