the MATTERS OF CONCERN as follows_ There is a clearly identifiable history that Canon Frost had become prone to falls and was unsteady on his feet Photographic evidence produced during the inquest of Canon Frost clearly demonstrates that the floor tiles in his kitchen had become loose and were no longer fastened to the floor: One of the floor tiles is completely out of position and the others appear to be loose with laraeqaps between the tiles themselves. In his witness statement Icommented "the flooring where Canon Frost would have fallen was very loose and could have been & trip hazard for Canon Frost Considering his frailty, the fact he lived alone and the medical conditions suffered by Canon Frost; on the available evidence this flooring was clearly not safe by any measure. In evidence it was heard that the flooring is sufficiently poor that it will need to be replaced prior to the re-occupation/sale of the property. Evidence heard that the Bishop of each diocese is responsible under 'canon law' for accommodating retired priests of the diocese This is generally done ona 'grace and favour tenancy of a diocesan owned property_There is no and graze said day hip

Tegal agreement for the occupation, but the general understanding is that the diocese provides the property and the retired priest is responsible for paying for all the service and maintaining the property. The retired priest receives an annual payment to cover the costs of services charges and general maintenance, It was heard that this is common practice in the 22 Roman Catholic dioceses of England and Wales.
5. It was heard in evidence that the diocese had a system of visits in place from the Welfare Officer and, if the retired priest was subject to a 'covenant of care' a Safeguarding Coordinator: Details of visits to Canon Frost's home were recorded as taking place in October 2010, December 2010, January 2011, July 2011, May 2012, January 2013,April 2014, August 2014, July 2016 and October 2017. In reports compiled in relation to these visits no mention is made of any health and safety or risk assessment activity being undertaken. A note from the October 2017 visit (11 months prior to Canon Frost's death) provides details of a recent fall in which Canon Frost fractured his hip, the fact he now used a walking frame and that his bedroom had been moved down stairs (following a visit from the local NHS Community Health Team): The property manager offered Canon Frost a visit from the Clergy Welfare Coordinator but this was declined. Despite identifying major factors regarding Canon Frost's mobility and increasing frailty, again no mention is made of any health and safety or risk assessment activity being undertaken: Giving the nature of the residents of these properties there is a degree of certainty that other 'grace and favour' residents will lose (or have already lost) the physical ability or the mental capacity to maintain their accommodation in a safe condition: On the evidence heard the system of welfare checks was not sufficiently robust and there was no independent assessment for health safety risks. It was apparent that the current system required the resident themselves family member or some other third party to raise such concerns when the fabric of the building is deteriorating: The resident themselves would then need to request for the work to be undertaken:
10. Dependant on the personal circumstance of each retired member of the clergy this system appears flawed, as it relies solely on the resident retaining the mental capacity andlor the physical ability to identify that a hazard exists and then make their own request for repairs. Without doubt; the welfare system currently in place failed to identify and remedy the fact that an obvious and serious trip hazard risk was present in Canon Frost's home
11. Given that this is the case am concerned that other residents of 'grace and favour' homes provided by the Bishop of each dioceses, may now also be in premises that may no longer be considered safe for their occupation_
12. During the hearing a submission was made by the lawyer representing the diocese involved that as the Local Community Health Team had also visited the property they should be included in this notice to which agreed. member of the Local Community Health Team visited Canon Frost on ne occasion 10th November 2017) who may have seen the condition of the flooring, and if so may have been in a position to report it: However; as the owner of the home the primary responsibility for ensuring it is safe for occupation, in my opinion falls to the Roman Catholic Church.