Emergency contingency plans
379 items
2 sources
Lack of pre-existing contingency plans for emergencies (e.g., pandemics), leading to a scramble and flawed early scheme design.
Cross-Source Insight
Emergency contingency plans has been flagged across 2 independent accountability sources:
229 inquiry recs
150 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (229)
BRIS-56 — Ensure management continuity during trust board Chair transition periods
Recommendation: Arrangements should be in place in the standing orders of trust boards to provide for proper continuity in the management of the trust’s affairs in the period between the cessation of the Chair’s term of office and the commencement of …
Unknown
HIDD-61 — Improve inter-service communication for major incident declarations via dedicated lines
Recommendation: The Emergency Services shall improve communication between them to ensure, in particular, that the declaration of a Major Incident by any service is immediately passed by a dedicated phone line to all other services and acted on by them . …
Unknown
HIDD-62 — Conduct regular major incident exercises to test emergency communication systems
Recommendation: Emergency services shall carry out exercises simulating a Major Incident on a regular basis to test specifically their communication systems in the light of the shortcomings identified in Chapter 5.
Unknown
HIDD-63 — Review ambulance procedures to provide early major incident warnings to hospitals
Recommendation: Ambulance services shall review procedures to ensure that the designated and supporting hospitals are given a major incident warning as early as possible.
Unknown
HIDD-64 — Ensure emergency alert lines receive incoming calls only and are tested weekly
Recommendation: Hospitals shall ensure that emergency alert telephone lines receive incoming calls only and are tested weekly. Switchboard operators shall be fully trained in their use and procedure.
Unknown
HIDD-65 — Implement training for Medical Incident Officers in radio communications usage
Recommendation: The LAS shall implement its proposal to train prospective Medical Incident Officers in the use of radio communications.
Unknown
HIDD-66 — Require hospitals to provide Medical Incident Officer training for relevant staff
Recommendation: Hospitals shall provide training in the duties of Medical Incident Officer for staff who could be called upon to act as such in the event of an accident.
Unknown
HIDD-67 — Require emergency services to provide local radio communication at accident sites
Recommendation: Emergency services shall provide local radio communication at the accident site to facilitate liaison between the control units and experts on site.
Unknown
HIDD-68 — Require Ambulance Service to provide hospital aerials for emergency radio communication
Recommendation: The Ambulance Service shall provide aerials at all designated hospitals for radio telephone communication in an emergency. The transmittedreceiver should be provided on declaration of a Major Incident.
Unknown
HIDD-69 — Require all emergency services to provide and ensure personnel wear protective clothing
Recommendation: All emergency services shall ensure that personnel are provided with and wear protective clothing, including protective headgear.
Unknown
HIDD-70 — Require services to provide coloured high-visibility vests for personnel identification
Recommendation: All emergency services, hospitals, BR and local authorities shall provide their personnel with coloured high visibility vests with the name of the service printed on it. Each service shall be easily identified by the colour of its emergency clothing.
Unknown
HIDD-71 — Require ambulance staff qualified in intubation to wear 'Millar trained' badges
Recommendation: Ambulance services shall require staff properly qualified in intubation and infusion to wear "Millar trained" badges prominently displayed, including on protective clothing.
Unknown
HIDD-72 — Require police casualty bureaux to be equipped with telephone queuing systems
Recommendation: Police forces shall arrange that all casualty bureaux be equipped with a telephone queuing system with a recorded message.
Unknown
HIDD-73 — ACPO to establish system for extending simultaneous casualty bureau call handling
Recommendation: The Association of Chief Police Officers shall continue their efforts to establish an effective system for extending the number of calls which can be dealt with simultaneously by a casualty bureau.
Unknown
HIDD-74 — Require emergency services to recognise Civil Police primacy in non-fire accidents
Recommendation: The emergency services shall recognise the primacy of the Civil Police authority in accidents of this kind where there is no fire. This recognition does not preclude delegation to the LFB of control at trackside.
Unknown
HIDD-75 — Require police forces to adopt Metropolitan Police arrangements for bereaved relatives
Recommendation: Police Forces shall study and follow the excellent arrangements made by the Metropolitan Police for the bereaved and relatives of the seriously injured.
Unknown
HIDD-76 — Require BR and emergency services to maintain joint planning with table-top exercises
Recommendation: In the exercise of command and control at accident sites BR and the emergency services shall maintain their policy of joint planning supported by table-top exercises.
Unknown
HIDD-77 — Require medical personnel to report to ambulance forward control unit on site
Recommendation: The ambulance service and designated hospitals shall require that all medical personnel report to the forward control unit of the ambulance service on site.
Unknown
HIDD-78 — Require each service to maintain up-to-date staff lists within inner cordon
Recommendation: Each service shall additionally maintain on site an up-to-date list of staff within the inner cordon in case evacuation is necessary.
Unknown
HIDD-79 — Department of Health to review Circular 71, clarifying Major Incident declaration terms
Recommendation: The Department of Health shall review DHSS Circular 71 in consultation with emergency and medical services to reflect all lessons learned but in particular in relation to procedures for declaring a Major Incident. The Department of Health shall specifically require …
Unknown
HIDD-80 — Department of Health to review BASICS' role and funding in emergency planning
Recommendation: In revising the Circular the Department of Health shall consider the role of BASICS in emergency planning and review BASICS' funding arrangements.
Unknown
HIDD-81 — BR to equip signal boxes with direct lines and emergency dialling systems
Recommendation: BR shall complete its programme of equipping major signal boxes with direct lines to the appropriate electrical control and equipping other signal boxes with priority emergency dialling systems. Those direct lines and emergency dialling systems shall be logged and tested …
Unknown
HIDD-82 — BR to review and test communication systems with emergency services weekly
Recommendation: BR shall review its communication systems with the emergency services to ensure that efficient methods exist to provide and disseminate early information requiring immediate action. In the course of the review BR shall look particularly at communication between signal boxes …
Unknown
HIDD-83 — BR to ensure proper training and clear instructions for new communication systems
Recommendation: BR shall ensure that those likely to use such systems in recommendations 81 and 82 above shall be properly trained in their use. Instructions in the use of these systems must be clearly drafted, prominently displayed and regularly checked for …
Unknown
HIDD-84 — Rectify high-priority deficiencies in railway communication systems and signal-post telephones
Recommendation: BR shall ensure that efficient arrangements exist to rectify as a matter of high priority any deficiencies in the communication systems involved in recommendations 81 and 82 and in signal-post telephones.
Unknown
HIDD-85 — Install public address systems in all new and older trains for passenger communication
Recommendation: BR shall extend its programme of installing public address systems in all new trains and those with a life of over 5 years to allow the driver and/or guard to speak to passengers.
Unknown
HIDD-86 — Produce updated accident procedure manual and provide staff with appropriate training
Recommendation: BR shall produce an up-to-date manual on Accident Procedure to replace such incomplete and out-of-date documents as the Southern Region Accident Procedure booklet of November 1984. BR shall ensure that all staff are given appropriate training in such procedures.
Unknown
HIDD-87 — Develop and regularly exercise effective emergency plans for all station staff
Recommendation: BR shall ensure that each area manager, station manager and all senior station staff have an effective emergency plan for their area that is understood by all their staff and is the subject of regular exercises.
Unknown
HIDD-88 — Introduce emergency signal override in signal boxes and update immobilised train procedures
Recommendation: BR shall introduce into all signal boxes the facility to switch all automatic signals to red in an emergency, and BR shall review and update where necessary its procedures to protect rail traffic in the vicinity of immobilised trains.
Unknown
HIDD-89 — Examine introducing short-circuiting bars with positive clamp on running rail
Recommendation: BR shall examine the possibility of introducing short-circuiting bars which achieve a positive clamp on the running rail.
Unknown
HIDD-90 — Detail evidence recording and preservation procedures within the accident procedure manual
Recommendation: BR shall set out in its manual on Accident Procedure the procedures that should be followed to ensure the proper recording and preservation of evidence.
Unknown
HIDD-91 — Ensure fault finding teams are accompanied by police and photographer for evidence
Recommendation: BR fault finding teams shall report to the Railway Incident Officer who, in consultation with the Police Incident Officer, shall ensure, in all but the most exceptional circumstances, that the team is accompanied by a police officer and a photographer …
Unknown
CR1 — Network flexing risk mitigation
Recommendation: Given the risks associated with HM Coastguard's use of network flexing for small boat search and rescue – whereby its workforce is split between different geographical locations – HM Coastguard must ensure the effectiveness of measures in mitigating them (including …
Response Pending
CR10 — Equipment and techniques development
Recommendation: HM Coastguard must continue to liaise with search and rescue partners in the UK and abroad to identify opportunities for the development or deployment of equipment and techniques to assist in search and rescue operations.
Response Pending
CR13 — Reconsider Border Force SAR function
Recommendation: The government should reconsider Mr Downer's recommendation in his independent review of Border Force that Border Force Maritime should not be providing an ongoing search and rescue function in the English Channel, with the result that HM Coastguard would assume …
Response Pending
CR14 — MoU between Coastguard and Border Force
Recommendation: For so long as the current arrangements in relation to search and rescue in the English Channel remain in place, the roles and responsibilities of HM Coastguard and Border Force should be set out in a memorandum of understanding.
Response Pending
CR15 — Joint training exercises plan
Recommendation: HM Coastguard should develop and implement a plan for joint training exercises, to occur at set intervals, with participation by those involved in maritime search and rescue in the English Channel and elsewhere.
Response Pending
CR16 — Mass rescue operation plan
Recommendation: HM Coastguard should develop a mass rescue operation plan that includes command and control, co-ordination, external stakeholders, medical and law enforcement roles, and public and external affairs.
Response Pending
CR3 — Regular assessment of assets and resources
Recommendation: There should be regular assessments by HM Coastguard of the adequacy of the available assets and human resources to respond to both current and reasonably foreseeable levels of small boat activity. Where the forecast level of resourcing need cannot be …
Response Pending
CR5 — Mass Persons in Water Triage procedure
Recommendation: Those involved in maritime search and rescue should adopt formally the Mass Persons in the Water Triage procedure to govern the operational response to a maritime search and rescue incident when the number of people requiring rescue exceeds the capability …
Response Pending
CR6 — Joint exercises on triage procedure
Recommendation: Those involved in maritime search and rescue should continue to undertake joint exercises on the application of the Mass Persons in the Water Triage procedure.
Response Pending
CR7 — IMO recommendation on triage tool
Recommendation: The Department for Transport must consider recommending to the International Maritime Organization that it consider incorporating an in-water mass casualty triage tool within its policies and procedures.
Response Pending
CR8 — Survivability advice to persons in distress
Recommendation: HM Coastguard should amend its existing policies to incorporate the need to provide more comprehensive advice about survivability to people in distress at sea.
Response Pending
CR9 — Cold water survivability modelling
Recommendation: HM Coastguard should examine whether it is using the most appropriate modelling for survivability in cold water. HM Coastguard should amend its existing policies to ensure that they consistently identify the key variables about which information is to be collected …
Response Pending
FENN-100 — Provide familiarisation training for all emergency services on London Underground
Recommendation: London Underground shall provide familiarisation training for members of all the emergency services.
Unknown
FENN-101 — Enforce smoking prohibition and review prosecution criteria on London Underground
Recommendation: London Underground and the British Transport Police must decide the most effective way to enforce the smoking prohibition and then train staff and officers accordingly. The criteria for prosecutions should be reviewed.
Unknown
FENN-107 — Display fire action posters in London Underground stations for public information.
Recommendation: London Underground should consider the display of posters in stations explaining action to be taken in the event of fire.
Unknown
FENN-11 — Agree and mark emergency services rendezvous and staff assembly points at stations.
Recommendation: A rendezvous point for the emergency services and a staff assembly point at each station must be agreed and marked.
Unknown
FENN-110 — Improve public address equipment quality and coverage across all station areas.
Recommendation: The quality and scope of public address equipment must be improved. It shall cover a wider area of stations.
Unknown
FENN-111 — Ensure British Transport Police and Fire Brigade radio compatibility in underground stations.
Recommendation: The radio equipment in underground stations for the British Transport Police must be made compatible with that used by the London Fire Brigade.
Unknown
FENN-112 — Regularly inspect, label, and report defective London Underground communications equipment for repair.
Recommendation: London Underground shall regularly inspect communications equipment. Where it is out of order it must be clearly labelled. Defective equipment must be immediately reported for repair.
Unknown
FENN-113 — Provide a new, properly equipped operations room at King's Cross station.
Recommendation: A new station operations room must be provided at King's Cross suitably located and properly equipped.
Unknown
FENN-114 — Improve station CCTV coverage and provide monitoring for British Transport Police.
Recommendation: Closed circuit television equipment shall be improved to allow coverage in colour of wider areas of stations. Monitoring facilities shall be provided in the British Transport Police L Division information room and line controllers' rooms.
Unknown
FENN-115 — Clearly mark station telephones, PA controls, and expand public payphone provision.
Recommendation: Platform and kiosk telephones, together with controls for public address equipment, must be clearly marked. At all telephone points there should be a list of key telephone numbers. An aide memoire of important telephone numbers should be issued to London …
Unknown
FENN-116 — Issue radios to station staff and ensure compatibility with tunnel equipment.
Recommendation: Station staff shall be issued with radios. Station radio equipment shall be made compatible with that used in the running tunnels.
Unknown
FENN-117 — Consider paging equipment as an alternative to personal radios for junior staff.
Recommendation: Paging equipment for junior station staff may be considered as an alternative to personal radios.
Unknown
FENN-118 — Provide public address equipment on all trains for crew and controller use.
Recommendation: There shall be public address equipment on all trains for use by the crew and the line controller.
Unknown
FENN-119 — Improve London Fire Brigade radio communications for firefighters operating below ground.
Recommendation: The London Fire Brigade must improve the means of radio communications between fire-fighters below ground.
Unknown
FENN-12 — Include evacuation by train within all station emergency evacuation plans.
Recommendation: Station evacuation plans should include evacuation by train.
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-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-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-124 — Survey secondary escape routes from stations and assess conversion costs.
Recommendation: London Underground shall undertake a survey to identify secondary means of escape from stations and the costs of conversion.
Unknown
FENN-125 — Study optimal methods for controlling smoke and ventilation in stations.
Recommendation: London Underground must study the best way in which smoke and ventilation can be controlled.
Unknown
FENN-126 — Mark station passages, lifts, staircases, escalators for easy identification.
Recommendation: London Underground shall mark passages, lifts, staircases and escalators in stations for easy identification.
Unknown
FENN-128 — Continue regular senior management safety meetings between LU, LFB, and RI.
Recommendation: The regular meetings at three levels of senior management between London Underground and the London Fire Brigade, and those between the Railway Inspectorate and the London Fire Brigade shall continue.
Unknown
FENN-13 — Regularly test water fog equipment and train staff in its use.
Recommendation: Water fog equipment must be regularly tested and staff trained in its use.
Unknown
FENN-14 — Agree principles for location and equipping of station operations rooms.
Recommendation: Principles for the location and equipping of station operations rooms must be agreed by all those concerned and followed by London Underground in their future planning.
Unknown
FENN-141 — London Underground to review ticketing system proposals with safety bodies
Recommendation: London Underground shall review its proposals for the working of the Underground Ticketing System (UTS) at stations and take advice from the Railway Inspectorate and the London Fire Brigade.
Unknown
FENN-148 — London Underground to regularly inform public about safety and changes
Recommendation: London Underground shall regularly inform the travelling public about safety on the Underground and any proposed changes.
Unknown
FENN-152 — Consider national disaster planning desk for experience and emergency coordination
Recommendation: Consideration should be given to a national disaster planning desk where the experience gained from disasters and their investigation and civil emergencies can be retained. Advice on the coordination of individual emergency plans should also be available at a national …
Unknown
FENN-17 — Provide computerised action checklist system for HQ controllers
Recommendation: The computerised action checklist system for the HQ controller (Gazetteer) shall be provided.
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-22 — BTP to attend pre-start meetings affecting passenger flow in stations
Recommendation: The British Transport Police shall also attend those pre-start meetings for works likely to affect passenger flow and movements in stations.
Unknown
FENN-23 — Review emergency services information exchange and appoint LFB liaison officers
Recommendation: The emergency services shall review the exchange of information between themselves and London Underground during an incident, both at their controls and at the site. The London Fire Brigade should send an officer to attend at London Underground HQ as …
Unknown
FENN-24 — Maintain station plan and key holder lists; BTP to hold station keys
Recommendation: The London Underground HQ controller and the British Transport Police L Division information room must maintain a list of the position of all station plans and key holders. British Transport Police officers shall hold or have access to keys for …
Unknown
FENN-28 — Strengthen links between London emergency services and British Transport Police
Recommendation: Links between the London emergency services and the British Transport Police shall be strengthened.
Unknown
FENN-33 — Review LAS procedures for removing casualties and bodies from major accidents
Recommendation: The London Ambulance Service shall review its procedures for the removal of casualties and bodies from the scene of a major accident.
Unknown
FENN-34 — Improve LAS senior officer attendance and command vehicle procedures at incidents
Recommendation: The London Ambulance Service shall improve its arrangements for the attendance of a senior incident officer when a major incident may develop and shall review the procedure for the attendance of its command and control vehicle at major accidents.
Unknown
FENN-47 — Ensure keys and communication equipment for unmanned locked station exit gates
Recommendation: Keys must always be readily available for unmanned locked gates at station exits. There shall be communication equipment or remote monitoring equipment at these gates.
Unknown
FENN-48 — Fit locked emergency gates with alarmed panic bars
Recommendation: Locked emergency gates shall be fitted with alarmed panic bars.
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-57 — Survey stations to recommend optimal equipment and staff for safety levels
Recommendation: In consultation with the emergency services the Chief Safety Inspector shall carry out a survey of each station in order to recommend the means of achieving satisfactory safety levels. The survey must particularly address the most effective combination of equipment …
Unknown
FENN-62 — Investigate passenger flow and congestion in stations, take remedial action
Recommendation: London Underground shall undertake an investigation of the problems of passenger flow and congestion in stations and take remedial action. They shall obtain advice from the London Fire Brigade and those with technical expertise. Reports of the most serious incidents …
Unknown
FENN-7 — Modify remote monitoring equipment to record smoke and heat detector activation
Recommendation: The remote monitoring equipment being fitted to escalators and lifts shall be modified so as to record any activation of smoke or heat detectors. This work should be completed by the end of 1989.
Unknown
FENN-70 — Prohibit alterations to operations rooms that reduce communications and control effectiveness
Recommendation: London Underground shall not permit alterations to any station operations room or supervisor's office which would reduce the effectiveness of communications and control.
Unknown
FENN-8 — Timed recording and retrieval system for all controller communications and messages
Recommendation: All messages received or made by HQ and line controllers must be timed and recorded with an effective retrieval system. A telephone system incorporating the most up-to-date facilities shall also be provided, as should data and video transmission equipment.
Unknown
FENN-82 — Provide biennial refresher training for management and supervisors on station emergency control
Recommendation: Every two years all management and supervisory staff shall receive refresher training in controlling station emergencies, and the use of fire and communications equipment.
Unknown
FENN-84 — Re-draft fire brigade calling instructions for staff in plain English
Recommendation: Instructions to staff as to the calling of the fire brigade shall be re-drafted in plain English. They must contain only relevant matter.
Unknown
FENN-88 — Conduct biannual joint emergency services exercises involving staff and public
Recommendation: There shall be a joint exercise with the emergency services at least twice each year. London Underground must involve as many different fire stations, staff and members of the public as possible.
Unknown
FENN-89 — Train all staff in emergency use of public address systems
Recommendation: All staff shall be trained in the emergency use of public address and other communications systems.
Unknown
FENN-9 — Agree station emergency instructions with LFB for staff training
Recommendation: Station instructions for emergencies and closure must be agreed with the London Fire Brigade and used in training station staff.
Unknown
FENN-90 — Train and practice London Underground incident officers in their duties
Recommendation: Potential London Underground incident officers must be trained and practised in their duties.
Unknown
FENN-95 — Train LFB personnel on station technical features and electrical isolation
Recommendation: London Underground shall train London Fire Brigade Personnel on technical features of stations, such as escalator and lift equipment, electrical controls and the means of isolating the electrical supply.
Unknown
FENN-97 — Train potential station supervisors in station evacuation and closure procedures
Recommendation: Potential station supervisors must be trained in the evacuation and closure of stations.
Unknown
FLIX-211 — Ensure ample nitrogen supplies for plants relying on nitrogen for safety
Recommendation: It is therefore recommended that all plants whose safety relies upon nitrogen should have nitrogen supplies which are ample to cover all contingencies. This means that there must be either adequate “in-house” supply or massive reserves.
Unknown
P1-16 — Develop policies for handling multiple FSG calls
Recommendation: All fire and rescue services develop policies for handling a large number of Fire Survival Guidance (FSG) calls simultaneously.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-17 — Electronic FSG recording and display systems
Recommendation: Electronic systems be developed to record FSG information in the control room and display it simultaneously at the bridgehead and in any command units.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-18 — Develop stay put to evacuation transition policies
Recommendation: Policies be developed for managing a transition from 'stay put' to 'get out'.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-20 — Investigate inter-control room information sharing
Recommendation: Steps be taken to investigate methods by which assisting control rooms can obtain access to the information available to the host control room.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-21 — LAS and MPS review FSG call protocols
Recommendation: The London Ambulance Service and Metropolitan Police Service review their protocols and policies to ensure that their operators can identify FSG calls (as defined by the LFB) and pass them to the LFB as soon as possible.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-22 — LFB improve deployment control policies
Recommendation: The LFB develop policies and training to ensure better control of deployments and the use of resources.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-23 — Improve crew debrief information systems
Recommendation: The LFB develop policies and training to ensure that better information is obtained from crews returning from deployments and that the information is recorded in a form that enables it to be made available immediately to the incident commander.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-25 — Investigate modern control room to bridgehead communications
Recommendation: The LFB investigate the use of modern communication techniques to provide a direct line of communication between the control room and the bridgehead, allowing information to be transmitted directly between the control room and the bridgehead and providing an integrated …
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-28 — National guidelines for high-rise evacuations
Recommendation: 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 …
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
Delivered
P1-29 — Fire services develop evacuation policies and training
Recommendation: Fire and rescue services develop policies for partial and total evacuation of high-rise residential buildings and training to support them.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-30 — Require evacuation plans for high-rise buildings
Recommendation: The owner and manager of every high-rise residential building be required by law to draw up and keep under regular review evacuation plans, copies of which are to be provided in electronic and paper form to their local fire and …
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted in Part
Delivered
P1-31 — Require evacuation alarm systems in high-rise buildings
Recommendation: All high-rise residential buildings (both those already in existence and those built in the future) be equipped with facilities for use by the fire and rescue services enabling them to send an evacuation signal to the whole or a selected …
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted in Part
In progress
P1-32 — Require personal emergency evacuation plans (PEEPs)
Recommendation: 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).
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted in Part
In progress
P1-33 — Require PEEP information in premises information box
Recommendation: 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.
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted in Part
Delivered
P1-35 — Require clear floor number markings in high-rise buildings
Recommendation: In all high-rise buildings floor numbers be clearly marked on each landing within the stairways and in a prominent place in all lobbies in such a way as to be visible both in normal conditions and in low lighting or …
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
Delivered
P1-36 — Require understandable fire safety instructions
Recommendation: 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 …
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
Delivered
P1-40 — Communicate Major Incident declarations to all responders
Recommendation: Each emergency service must communicate the declaration of a Major Incident to all other Category 1 Responders as soon as possible.
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
Delivered
P1-41 — Establish inter-service control room communications
Recommendation: On the declaration of a Major Incident clear lines of communication must be established as soon as possible between the control rooms of the individual emergency services.
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
Delivered
P1-42 — Designate single point of contact in control rooms
Recommendation: A single point of contact should be designated within each control room to facilitate such communication.
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
Delivered
P1-43 — Use METHANE messages for Major Incidents
Recommendation: A 'METHANE' (Major incident declared, Exact location, Type of incident, Hazards, Access, Number and type of casualties, Emergency services present and required) message should be sent as soon as possible by the emergency service declaring a Major Incident.
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
Delivered
P1-44 — Investigate LFB-MPS-LAS system compatibility
Recommendation: Steps be taken to investigate the compatibility of the LFB systems with those of the MPS and the LAS with a view to enabling all three emergency services' systems to read each other's messages.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-45 — NPAS helicopter datalink encryption standards
Recommendation: Steps be taken to ensure that the airborne datalink system on every NPAS helicopter observing an incident which involves one of the other emergency services defaults to the National Emergency Service user encryption.
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted in Part
Delivered
P1-46 — Improve survivor information collection and sharing
Recommendation: The LFB, the MPS, the LAS and the London local authorities all investigate ways of improving the collection of information about survivors and making it available more rapidly to those wishing to make contact with them.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P2-11 — Develop new test methods for evacuation strategy assessments
Recommendation: Assessing whether an external wall system can support a particular evacuation strategy is difficult because the necessary information is not always available. We therefore recommend that steps be taken in conjunction with the professional and academic community to develop new …
Gov response: The government accepts this recommendation. We will work with the professional and academic community to address this recommendation through the ongoing Approved Document B review led by the Building Safety Regulator which will consider any …
Accepted
In progress
P2-42 — Review Civil Contingencies Act intervention powers
Recommendation: That the [Civil Contingencies] Act [2004] be reviewed and consideration be given to granting a designated Secretary of State the power to carry out the functions of a Category 1 responder in its place for a limited period of time. …
Gov response: The government accepts this recommendation. The Cabinet Office will review statutory interventions powers, in consultation with other government departments.
Accepted
In progress
P2-43 — Require voluntary sector partnerships in contingency planning
Recommendation: Regulation 23 of the Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005 requires a Category 1 responder to have regard when making its plans to the activities of relevant voluntary organisations. We therefore recommend that the regulation be amended to …
Gov response: The government accepts this recommendation in principle. We acknowledge the vital role of the voluntary, community and faith sector (VCFS) in all aspects of resilience and are committed to building stronger relationships and collaboration with …
Accepted in Part
In progress
P2-44 — Consolidate and update emergency preparedness guidance
Recommendation: The current guidance on preparing for emergencies is contained in several documents, all of which are unduly long and in some respects out of date. We recommend that the guidance be revised, reduced in length and consolidated in one document …
Gov response: The government accepts this recommendation. We will fully factor it into the outcomes of the resilience review. As a first step, we will publish the revised local responder guidance on 'Identifying and Supporting Vulnerable People' …
Accepted
In progress
P2-46 — Revise London Gold arrangements guidance
Recommendation: Events demonstrated, however, that there is a need for a clearer understanding of the nature of the London Gold arrangements, in particular in situations in which a single borough is affected. We therefore recommend that the guidance on the operation …
Gov response: The government supports this recommendation made towards London local authorities and the London Local Authorities Regional Resilience Board. London's resilience structures are set out under the Civil Contingencies Act 2004 and its statutory guidance, Emergency …
Accepted
In progress
P2-47 — Local resilience forums to adopt national standards
Recommendation: That local resilience forums adopt national standards to ensure effective training, preparation and planning for emergencies and adopt independent auditing schemes to identify deficiencies and secure compliance. (113.71)
Gov response: The government accepts this recommendation. We will refine and update the National Resilience Standards for Local Resilience Forums (LRFs) to clarify expectations on local resilience forums. Further work will be undertaken to determine appropriate levels …
Accepted
In progress
P2-48 — Verify training quality of Category 1 responders
Recommendation: That a mechanism be introduced for independently verifying the frequency and quality of training provided by local authorities and other Category 1 responders. (113.71)
Gov response: The government accepts this recommendation made towards Category 1 responders in principle. There are a number of regulatory and inspectorate bodies across the range of responder organisations to support them to meet their responsibilities under …
Accepted in Part
In progress
P2-49 — Train all local authority employees on resilience
Recommendation: That local authorities train all their employees, including chief executives, to regard resilience as an integral part of their responsibilities. (113.73)
Gov response: The government supports this recommendation made towards local authorities. We expect all relevant staff to be provided with the necessary training. Local authorities should be empowered to determine which of their staff should undertake training …
Accepted
In progress
P2-50 — Devise displaced person information recording methods
Recommendation: RBKC had no effective means of collecting and recording information about those who had been displaced from the tower and surrounding buildings, including those who were missing. Compiling reliable information of that kind is difficult and the challenges likely to …
Gov response: The government supports this recommendation made towards local authorities. This responsibility will be highlighted in guidance that clarifies key duties on local authorities. We note that the ability and requirement to do this will be …
Accepted
In progress
P2-51 — Arrange emergency temporary accommodation provision
Recommendation: That all local authorities make such arrangements as are reasonably practicable for enabling them to place people in temporary accommodation at short notice and in ways that meet their personal, religious and cultural requirements. Such arrangements should, as far as …
Gov response: The government supports this recommendation made towards local authorities. Local authorities already have a legal obligation under the Housing Act 1996 to re-house people displaced by an emergency. This duty will be highlighted in guidance …
Accepted
In progress
P2-52 — Include financial assistance in contingency plans
Recommendation: That all local authorities include in their contingency plans arrangements for providing immediate financial assistance to people affected by an emergency. (113.76)
Gov response: The government supports this recommendation made towards local authorities. Local authorities understand their local areas and contingency plans best, but government is committed to working with local authorities and the Local Government Association to understand …
Accepted
In progress
P2-53 — Plan for key worker availability in emergencies
Recommendation: That as part of their planning for emergencies local authorities give detailed consideration to the availability of key workers and the role they are expected to play so that suitable contingency arrangements can be made to ensure, as far as …
Gov response: The government supports this recommendation made towards local authorities, noting that this recommendation is made in reference to social workers. MHCLG is committed to working with the Department for Health and Social Care, the Department …
Accepted
In progress
P2-54 — Establish effective emergency communication methods
Recommendation: That as part of their emergency planning local authorities make effective arrangements for continuing communication with those who need assistance using the most suitable technology and a range of languages appropriate to the area. (113.77)
Gov response: The government supports this recommendation made towards local authorities. Local authorities already have a legal obligation through their duties under the Civil Contingencies Act 2004. This duty will be highlighted in guidance that clarifies key …
Accepted
In progress
P2-55 — Use modern communication for public emergency information
Recommendation: That all local authorities include in their plans for responding to emergencies arrangements for providing information to the public by whatever combination of modern methods of communication are likely to be most effective for the areas for which they are …
Gov response: The government supports this recommendation made towards local authorities. Local authorities already have a legal obligation through their duties under the Civil Contingencies Act 2004. This duty will be highlighted in guidance that clarifies key …
Accepted
In progress
SHEE-28 — Fit fail-safe indicator lights and dedicated alarm panel for superstructure doors
Recommendation: The lights should not only indicate in a suitable position on the bridge, but the entire circuit should be designed on a fail-safe basis so that if there should be an electrical failure in any switch circuit the system would …
Unknown
SHEE-29 — Fit closed-circuit television monitoring for all superstructure doors
Recommendation: We have no doubt that closed circuit television monitoring of all superstructure doors, is well worthwhile and should be fitted.
Unknown
SHEE-30 — Alter UK berths to allow ships to shut bow and stern doors
Recommendation: It follows that if ships cannot shut their doors at a particular berth, because of the design of that berth, then alterations should be made to the berth. Alterations have been made to some berths, but it is considered by …
Unknown
SHEE-31 — Require approved draught gauges for Ro/Ro ferries with multiple readouts
Recommendation: The Court concludes that mechanical, pneumatic, electrical or hydrostatic draught gauges or indicators should be a requirement for Ro/Ro passenger ferries, using types specifically investigated and approved by the Department. These gauges or indicators should be fitted to give readout …
Unknown
SHEE-32 — Adopt and regularly review updated nominal weights for cars and coaches
Recommendation: The practice of using one metric tonne for the all-up weight of the average car with luggage, fuel, and personal effects, is outmoded. A nominal weight of metric tonnes should be adopted. This figure should be reviewed regularly by the …
Unknown
SHEE-33 — Require Port Authorities to provide rolling weigh-bridges for freight vehicles
Recommendation: In view of the uncertainty as to the actual weights of many freight vehicles every effort should be made to persuade, or even require, Port Authorities to provide rolling weigh-bridges, possibly of the loadcell type, where all freight vehicles coming …
Unknown
SHEE-35 — Urgently fit approved, watertight emergency lighting units on Ro/Ro ferries
Recommendation: As a matter of urgency, self-contained, maintained emergency lighting units of a type approved by the Department should be fitted to all Ro/Ro passenger ferries in suitable numbers and in such places as may be advised by the Department. It …
Unknown
SHEE-37 — Standardise reliable, openable escape windows for lifeboat and embarkation stations
Recommendation: If laminated safety glass is to be used in windows in way of lifeboat and embarkation stations, it is clear that they should, if possible, be fitted in push-out or centre line hinged window frames in situations where rapid exit …
Unknown
SHEE-38 — Discourage slab-sided vessel design and improve athwartships escape routes
Recommendation: The Court thinks that in general, the design of slab sided vessels should be discouraged. Consideration should be given to whether such sills should be higher, say 600 mm. Athwartships doors should be provided at recognised intervals; and thought should …
Unknown
SHEE-39 — Develop simple methods for bridging shafts in passenger compartments
Recommendation: While suggestions have been made as to the desirability of finding some means of bridging these shafts, it is the view of the Department of Transport that this is not really practicable. the Court is not convinced by this. It …
Unknown
SHEE-42 — Require standard envelope curves and trim data for all ferries
Recommendation: There should be a requirement in the PSC & S Regulations for standard envelope curves, at least for level keel and trims by the stern and by the head of, say, 0.4% and 0.8% of the length of the ship. …
Unknown
SHEE-43 — Urgently re-incline all ferries not re-inclined within four years
Recommendation: Not only should the SPIRIT class vessels be re-inclined, but all existing ferries that have not been re-inclined within the last 4 years should be re-inclined as a matter of urgency to assess their current lightship weights and centres of …
Unknown
SHEE-44 — Update Stability Booklets with trim limits and metacentric height checks
Recommendation: The Department should state that trims should never exceed certain limits, or alternatively and preferably, hydrostatic data for large trims should be included in the Stability Booklet, but noted as being for harbour guidance only. Furthermore, the Stability Book should …
Unknown
SHEE-48 — Investigate increasing margin line distance to bulkhead deck for new Ro-Ro designs
Recommendation: The Court recommends that detailed investigations and model tests should be carried out with a view to increasing the required distance from the margin line to the bulkhead deck in new design Ro-Ro passenger ferries to perhaps 1 m. The …
Unknown
SHEE-49 — Phase out or limit life of vessels not meeting 1980 safety standards
Recommendation: Immediate consideration should be given to phasing out vessels built under the 1965 rules unless they meet or can be modified to meet, at least, the 1980 standards in these respects, as they may be substantially less safe than modern …
Unknown
SHEE-50 — Investigate methods to improve Ro-Ro ferry survivability, including portable bulkheads
Recommendation: Alternatively there are lines of investigation that should be pursued urgently with the object of finding methods of improving the survivability of Ro-Ro passenger ferries. It is concluded that a feasibility exercise should be carried out to investigate the practical …
Unknown
SHEE-51 — Improve safety of vehicle deck access openings and increase sill heights
Recommendation: In conjunction with all such arrangements, detailed consideration should be given to access openings from the vehicle deck. Sill heights should be increased appreciably. Wherever possible access to spaces such as the engine room and below bulkhead deck passenger accommodation …
Unknown
SHEE-52 — Investigate and urgently clarify conflicts between IMO and other regulations
Recommendation: This conflict between I.M.O. and other Regulations should be investigated and clarified as a matter of urgency.
Unknown
SHEE-54 — Improve prevention of water reaching Ro-Ro ferry vehicle decks during damage
Recommendation: There is a fourth area which is apparently missing namely:- Improvement in the prevention of water reaching the vehicle deck in the event of damage occurring in realistic seagoing conditions. The latter area is as important as the other three …
Unknown
SHEE-56 — Review philosophy of carrying lifeboats on ships operating close to land
Recommendation: It is the view of this Court that the time has now come when the whole philosophy of carrying lifeboats on ships which are never far from land should be reviewed by the International Maritime Organisation. The Court recommends that …
Unknown
9 — National patient recall framework
Recommendation: We recommend that a national framework or protocol, with guidance, is developed about how recall of patients should be managed and communicated, centred around the needs of the patients and applicable in both the independent sector and the NHS.
Gov response: Accepted and implemented. NHS England published the National Quality Board Recall Framework on 1 June 2022, developed with input from Paterson patients. The framework establishes principles for patient-centred recall in secondary care across both NHS …
Accepted
Delivered
P2-17 — Recommendations apply to temporary facilities
Recommendation: Trust boards should ensure that these recommendations and governance arrangements are applied to any temporary facilities used by trusts for the storage and care of deceased people.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-54 — Local authority contingent body storage plans
Recommendation: Local authorities providing a coroner service must review plans for the provision and operation of contingent body storage, in collaboration with local organisations providing mortuary services.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
LADB-1 — Computerise system for managing missing persons and casualty information
Recommendation: The system for the reception of information about missing persons, casualties and survivors should be computerised. It should be possible for information which has been received to be entered directly into the computer and for information from it to be …
Unknown
LADB-2 — Extend computerisation to all police forces for shared information access
Recommendation: Computerisation should be extended to all police forces, so that the information collated by each is readily available to all others (para 4.120).
Unknown
LADB-3 — Establish common telephone numbers for public major incident information
Recommendation: The police service, in co-operation with the emergency services, should use their best endeavours to ensure that common telephone numbers are issued for the use of members of the public who are seeking to give or obtain information about persons …
Unknown
LADB-4 — Review railway emergency planning, including survivor after-care and bereaved support
Recommendation: The Railway Group should review emergency planning, including liaison with the emergency services, arrangements for the after-care of survivors and the provision of support and facilities for the bereaved and injured (para 4.122).
Unknown
LADB-83 — Assess feasibility and risk of incorporating escape hatches in all train carriages.
Recommendation: The incorporation of escape hatches in existing carriages should be the subject of feasibility and risk assessment and the provision of escape hatches in new carriages should likewise be considered (para 14.54).
Unknown
LADB-84 — Train all on-board train staff in evacuation and protection procedures.
Recommendation: All members of the on-board train staff (including persons working under contract) should be persons who have been trained in train evacuation and protection (para 14.62).
Unknown
LADB-85 — Study passenger-to-signaller communication systems for driver-only trains in emergencies.
Recommendation: The possibility of installing on driver-only trains a telephone by which passengers can communicate with the signaller in the event of the driver being killed or incapacitated should be studied (para 14.65).
Unknown
LADB-86 — Examine feasibility of a "roaming" communication system for train staff.
Recommendation: The feasibility of a “roaming” communication system for train staff should be examined (para 14.68).
Unknown
LADB-87 — Investigate implementing remote broadcasting from outside the train where unavailable.
Recommendation: The possibility of remote broadcasting from outside the train, where it is not already available, should be investigated (para 14.68).
Unknown
MAI-107 — Ensure immediate HART resource deployment
Recommendation: The Department of Health and Social Care and the National Ambulance Resilience Unit should develop procedures to ensure that, so far as possible, each ambulance service trust is able to deploy or call upon HART resources immediately in the event …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-130 — Public Access Trauma kit availability
Recommendation: The Home Office and the Department of Health and Social Care should consider how to ensure Public Access Trauma kits are available in all locations where they are most likely to be needed.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-157 — Review stretcher availability for mass casualties
Recommendation: The Home Office, the Department of Health and Social Care, the Department for Transport and the Department for Levelling Up, Housing and Communities should conduct a review to ensure that stretchers that are appropriate in design and adequate in numbers …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
MAI-42 — SMG sharing of emergency response plans
Recommendation: SMG should review its processes to ensure that it shares with Greater Manchester Police, Greater Manchester Fire and Rescue Service, British Transport Police and North West Ambulance Service its most current emergency response plans and policies for dealing with an …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
MAI-44 — Ambulance trusts submit resource recommendations
Recommendation: Having carried out that review, the trusts should make recommendations to their NHS commissioners about the additional and/or different resources they require in order to ensure that they are able to respond effectively to a mass casualty incident in the …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-46 — Guidance on Major Incident plan review frequency
Recommendation: His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing and the Home Office should issue guidance for all police services on how often operational plans for responding to a Major Incident, including a terrorist incident, …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-47 — Sufficient resources for operational planning
Recommendation: His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing and the Home Office should work together to put in place robust systems, policies and guidance to ensure that all police services have sufficient resources dedicated …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
CLAR-13.53.2 — Secretary of State to direct formal investigation includes search and rescue operation
Recommendation: Although I take the view that the remit of a formal investigation would include the search and rescue operation, I recommend that the Secretary of State give an express direction to that effect in accordance with regulation 4(1) of the …
Unknown
CLAR-2 — Secretary of State to direct formal investigation includes search and rescue operation
Recommendation: Although I take the view that the remit of a formal investigation would include the search and rescue operation, I recommend that the Secretary of State give an express direction to that effect in accordance with regulation 4(1) of the …
Unknown
F122 — Handling large-scale complaints
Recommendation: Large-scale failures of clinical service are likely to have in common a need for: Provision of prompt advice, counselling and support to very distressed and anxious members of the public; Swift identification of persons of independence, authority and expertise to …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F138 — Local scrutiny
Recommendation: Commissioners should have contingency plans with regard to the protection of patients from harm, where it is found that they are at risk from substandard or unsafe services.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
POPP-A.1 — Integrate evacuation procedures into police training and pre-match briefings.
Recommendation: Evacuation procedures should be a matter of police training and form part of the briefing by police officers before a football match.
Unknown
POPP-A.10 — Train stewards in fire safety, firefighting, and assisting police with evacuation.
Recommendation: Stewards in all grounds should not only be trained in fire precautions and fire fighting (see Recommendation 7 above) but should also be trained in how best to help the police in evacuation.
Unknown
POPP-A.11 — Amend Green Guide to require manned, openable exit gates during public use.
Recommendation: Paragraphs 6.14.6 of the Green Guide should be amended to read: “All exit gates should be manned at all times while the ground is used by the public and be capable of being opened immediately from inside by anyone in …
Unknown
POPP-A.12 — Amend Green Guide for comprehensive steward training and instruction on emergencies.
Recommendation: The Green Guide should be amended to contain a specific provision, in relation to stewards, (i) that they should be trained and instructed to deal with any emergency relating to fire or evacuation (see also Recommendations 7 and 10); (ii) …
Unknown
POPP-A.14 — Ensure all sports grounds provide suitable and adequate emergency exits.
Recommendation: Suitable and adequate exits should be provided in all sports grounds.
Unknown
POPP-A.18 — Develop best practice for managing safety of temporary stands and marquees.
Recommendation: Consideration should be given as how best to deal with temporary stands and marquees.
Unknown
POPP-A.24 — Design standard efficient perimeter fences including proper exits
Recommendation: Consideration should be given to the design of a standard, efficient perimeter fence, with proper exits.
Unknown
RHI-34 — Rapid Response Capacity
Recommendation: The Northern Ireland Civil Service should have regard to best practice elsewhere about how to respond effectively when serious problems emerge, such as those that did so with the non-domestic NI RHI in the summer of 2015, by, for example, …
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
Delivered
TAYL-F27 — Immediately review all Safety Certificates with stakeholders and stadium inspection
Recommendation: There should be an immediate review of each Safety Certificate (if this has not already been don< following the Interim Report) by the responsible local authority, which should consult the club in respect oi which the Certificate is issued, the …
Unknown
TAYL-F31 — Local authorities should establish an Advisory Group for crowd safety oversight
Recommendation: To assist the local authority in exercising its functions, it should set up an Advisory Group (if this has not already been done) consisting of appropriate members of its own staff, representatives of the police, of the fire and ambulance …
Unknown
TAYL-F43 — Provide well-placed, spacious, and equipped police control room with CCTV
Recommendation: The club s,hould provide a police control room which is:- (a) well placed, so as to command a good view of the whole pitch and of the spectator area surrounding it; (b) of sufficient size for the commander, his deputy …
Unknown
TAYL-F45 — Alert officers to prevent and remedy overcrowding through operational orders and briefings
Recommendation: The Operational Order for each match at a designated sports ground, and the pre-match briefing of all officers on duty there, should alert such officers to the importance of preventing any overcrowding and, if any is detected, of taking appropriate …
Unknown
TAYL-F46 — Operational orders ensure police cope with spectator flow and rapid deployment
Recommendation: The Operational Order for each match at a designated sports ground should enable the police to cope with any foreseeable pattern in the arrival of spectators at a match and in their departure. It should provide for sufficient reserves to …
Unknown
TAYL-F47 — Police planning must prevent ticketless fans entering designated sports grounds
Recommendation: Police planning should provide that ticketless fans should not be allowed to enter a designated sports ground except in an emergency.
Unknown
TAYL-F49 — Officer in command may postpone kick-off, prioritising crowd safety
Recommendation: The option to postpone kick-off should be in the discretion of the officer in command at the ground. Crowd safety should be the paramount consideration in deciding whether to exercise it.
Unknown
TAYL-F51 — Provide control room with CCTV and turnstile data; train officers in interpretation
Recommendation: There should be available in the police control room the results of all closed circuit television monitoring outside and inside the ground and the record of any electronic or mechanical counting of numbers at turnstiles or of numbers admitted to …
Unknown
TAYL-F54 — Ensure sufficient operators and priority radio channels for police control rooms
Recommendation: There should be sufficient operators in the police control room to enable all radio transmissions to be received, evaluated and answered. The radio system should be such as to give operators in the control room priority over, and the capacity …
Unknown
TAYL-F55 — Establish dedicated command radio channel for Police Commander and senior officers
Recommendation: There should always be a command channel reserved solely for the Police Commander to communicate with his senior officers round the ground.
Unknown
TAYL-F56 — Implement separate landline telephone system between control room and key ground points
Recommendation: To complement radio communications, there should be a completely separate system of land lines with telephone links between the control room and key points at the ground.
Unknown
TAYL-F57 — Install public address system with alert signal for stadium crowd communication
Recommendation: Within the control room, there should be a public address system to communicate with individual areas outside and inside the ground, with groups of areas or with the whole ground. Important announcements should be preceded by a loud signal to …
Unknown
TAYL-F59 — Require regular inter-service liaison on crowd safety at designated sports grounds
Recommendation: The police, fire and ambulance services should maintain through senior nominated officers regular liaison concerning crowd safety at each designated sports ground.
Unknown
TAYL-F60 — Require police to share full pre-match details with emergency services
Recommendation: Before each match at a designated sports ground the police should ensure that the fire service and ambulance service are given full details about the event, including its venue, its timing, the number of spectators expected, their likely routes of …
Unknown
TAYL-F61 — Maintain instant communication links between police and emergency service headquarters
Recommendation: Lines of communication, whether by telephone or by radio, from the police control room to the local headquarters of all emergency services should be maintained at all times so that emergency calls can be made instantly.
Unknown
TAYL-F62 — Review emergency vehicle access, rendezvous points, and internal ground accessibility
Recommendation: Contingency plans for the arrival at each designated sports ground of emergency vehicles from all three services should be reviewed. They should include routes of access, rendezvous points, and accessibility within the ground itself.
Unknown
TAYL-F63 — Brief entrance police on emergency service plans and deployment information
Recommendation: Police officers posted at the entrances to the ground should be briefed as to the contingency plans for the arrival of emergency services and should be informed when such services are called as to where and why they are required.
Unknown
TAYL-F64 — Require one trained first aider per 1,000 spectators at sports grounds
Recommendation: There should be at each sports ground at each match at least one trained first aider per 1,000 spectators. The club should have the responsibility for securing such attendance.
Unknown
TAYL-F65 — Mandate equipped first aid rooms as Safety Certificate requirement
Recommendation: There should be at each designated sports ground one or more first aid rooms. The number of such rooms and the equipment to be maintained within them should be specified by the local authority after taking professional medical advice and …
Unknown
TAYL-F66 — Require medical practitioner presence for matches exceeding 2,000 spectators
Recommendation: (a) At every match where the number of spectators is expected to exceed 2,000, the club should employ a medical practitioner to be present and available to deal with any medical exigency at the ground. He should be trained and …
Unknown
TAYL-F67 — Mandate one fully equipped ambulance for matches with 5,000+ spectators
Recommendation: At least one fully equipped ambulance from or approved by the appropriate ambulance authority should be in attendance at all matches with an expected crowd of 5,000 or more.
Unknown
TAYL-F68 — Specify ambulance numbers for large crowds as Safety Certificate requirement
Recommendation: The number of ambulances to be in attendance for matches where larger crowds are expected should be specified by the local authority after consultation with the ambulance service and should be made a requirement of the Safety Certificate.
Unknown
TAYL-F69 — Deploy major incident equipment vehicle for crowds exceeding 25,000
Recommendation: A "major incident equipment vehicle", designed and equipped to deal with up to SO casualties, should be deployed in addition to other ambulance attendance at a match where a crowd in excess of 25,000 is expected.
Unknown
TAYL-I10 — Provide cutting equipment for perimeter fences, train users, senior police decide
Recommendation: Suitable and sufficient cutting equipment should be provided by the club at each ground where there are perimeter fences to permit the immediate removal of enough fencing to release numbers of spectators if necessary. Agreement should be reached as to …
Unknown
TAYL-I37 — Review emergency vehicle contingency plans, including access and rendezvous points
Recommendation: Contingency plans for the arrival at each designated stadium of emergency vehicles from all three services should be reviewed. They should include routes of access, rendezvous points, and accessibility within the ground itself.
Unknown
TAYL-I38 — Brief entrance police officers on emergency service contingency plans and deployment
Recommendation: Police officers posted at the entrances to the ground should be briefed as to the contingency plans for the arrival of emergency services and should be informed when such services are called as to where and why they are required.
Unknown
COVID-M2.10 — Pandemic Decision-Making Framework
Recommendation: The UK government and devolved administrations should set out in future pandemic preparedness strategies how decision-making will work in a future pandemic. This should include provision for COBR to be used as the initial response structure and set out how …
Gov response: No government response yet received. Module 2 report published 20 November 2025.
Response Unclear
COVID-M2.11 — Leadership Succession Arrangements
Recommendation: The UK government and the devolved administrations should each establish formal arrangements for covering the roles of Prime Minister and First Minister (and in Northern Ireland, deputy First Minister) as applicable during a whole-system civil emergency, should the incumbent be …
Gov response: No formal response published by this government.
Unknown
COVID-M2.12 — Central Emergency Taskforces
Recommendation: The response to a future whole-system civil emergency should be coordinated via central taskforces in each of the UK, Scotland, Wales and Northern Ireland, with responsibility for the commissioning and synthesis of advice, coordination of a single data picture and …
Gov response: No formal response published by this government.
Unknown
COVID-M2.16 — Civil Contingencies Act Review
Recommendation: The UK government should undertake a review of the Civil Contingencies Act 2004 to assess its potential role in managing future civil emergencies, including pandemics, and whether it could be employed as an interim emergency framework until more specific legislation …
Gov response: No government response yet received. Module 2 report published 20 November 2025.
Response Unclear
COVID-M2.18 — Devolved Nations COBR Attendance
Recommendation: The UK government should invite the devolved administrations, as a matter of standard practice, to nominate relevant ministers and officials to attend COBR meetings in the event of relevant whole-system civil emergencies that have the potential to have UK-wide effects.
Gov response: No government response yet received. Module 2 report published 20 November 2025.
Response Unclear
COVID-M2.19 — Four Nations Pandemic Structure
Recommendation: While intergovernmental relations should be facilitated through COBR in the initial months of any future pandemic, the UK government and devolved administrations should ensure that a specific four-nations structure, concerning pandemic response, is stood up at the same time as …
Gov response: No formal response published by this government.
Unknown
COVID-M2.8 — Vulnerable People Framework
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should each agree a framework that identifies people who would be most at risk of becoming infected by and dying from a disease and those who are most likely …
Gov response: No formal response published by this government.
Unknown
COVID-M3.1 — IPC Structures and Transmission Risk
Recommendation: The UK government must ensure that there is a body (equivalent to the UK Infection Prevention and Control Cell) in place ready to be convened at the outset of any future pandemic, to consider and draft infection prevention and control …
Gov response: No formal response published by this government.
Unknown
COVID-M3.10 — Healthcare Worker Support
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with healthcare employers and professional bodies, should put in place plans to deliver effective support for healthcare workers at scale from the outset of a pandemic. Plans should …
Gov response: No formal response published by this government.
Unknown
COVID-M3.2 — Visiting Restrictions Guidance
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should publish guidance for the implementation of visiting restrictions in hospitals in the event of a future pandemic. The guidance should identify the circumstances in which visiting restrictions should …
Gov response: No formal response published by this government.
Unknown
COVID-M3.3 — Fit-Testing Preparedness
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with employers, including health boards and trusts, to review the availability of qualified fit testers and take steps to increase the number of fit testers accordingly. Availability …
Gov response: No formal response published by this government.
Unknown
COVID-M3.4 — Data Systems for High-Risk Individuals
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive must ensure that health data and digital systems have the capability to identify individuals at high risk of morbidity or mortality from a pandemic disease quickly and accurately in …
Gov response: No formal response published by this government.
Unknown
COVID-M3.5 — Scale Up Urgent and Emergency Care
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, in conjunction with organisations responsible for delivering services, should plan for surge capacity in urgent and emergency care during a pandemic. Plans must ensure that there is sufficient workforce …
Gov response: No formal response published by this government.
Unknown
COVID-M3.6 — Scale Up Hospital Capacity
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with trusts and health boards to ensure that pandemic plans include practical steps to rapidly scale up hospital capacity to treat acutely unwell patients. This should include …
Gov response: No formal response published by this government.
Unknown
COVID-M3.7 — ICU Resource Allocation Framework
Recommendation: The UK government and devolved administrations should publish a UK-wide framework setting out ethical and operational principles to guide the allocation of adult intensive care resources in the extreme event that they are saturated during a pandemic. That framework must: …
Gov response: No formal response published by this government.
Unknown
COVID-M3.9 — Standardised Advance Care Planning
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with trusts and health boards, should establish and promote one standardised process across the UK (such as ReSPECT, the Recommended Summary Plan for Emergency Care and Treatment) for …
Gov response: No formal response published by this government.
Unknown
R4 — Local HAI Task Forces
Recommendation: Scottish Government should develop local healthcare Associated infection (HAI) Task Forces within each Health Board area.
Gov response: Section 2.1 of the Scottish Government's response states that the national Healthcare Associated Infection (HAI) Taskforce has been restructured into a smaller, more focused group. This group 'will work with local teams and existing structures …
Accepted
R50 — 24/7 IPC cover
Recommendation: Health Boards should ensure that there is 24-hour cover for infection prevention and control seven days a week, and that contingency plans for leave and sickness absence are in place.
Gov response: Section 4.1 of the Scottish Government's response discusses general workforce planning, including the use of nursing and midwifery workload and workforce planning tools to determine the number of nurses or midwives needed. However, the provided …
Accepted
R6 — Service change continuity plans
Recommendation: Scottish Government should ensure that where major changes in patient services are planned there should be clear and effective plans in place for continuity of safe patient care.
Gov response: Section 2.1 of the Scottish Government's response details the intention to develop a longer-term plan for health and social care, and the integration of health and social care services. This integration aims to improve care, …
Accepted
PFD Reports (150) — showing 100 most recent
Edward Jones
Concerns: There is no nationally validated sepsis screening tool for Paediatric Emergency Departments, and the trust's own tool lacks consistent application between departments.
Pending
Andrew Hughes
Concerns: The 'Right Care Right Person' system lacks clarity on how concerned families can access emergency mental health services, and there is insufficient provision for such emergencies in Greater Manchester.
Response: Greater Manchester Integrated Care clarified that mental health services provide a crisis response, not an emergency response, which is the responsibility of 999 services. They acknowledge an ongoing risk regarding …
Response: The Deputy Mayor clarifies that their role is one of scrutiny and oversight for RCRP implementation, not operational accountability for GMP or partner agencies. They suggest future Regulation 28 notices …
Responded
Imogen Nunn Prevention of future deaths report
Concerns: A national shortage and lack of regulation for British Sign Language interpreters, alongside procurement issues and few BSL-proficient clinicians, create significant risks for deaf mental health patients.
Response: The Department for Education acknowledges concerns regarding BSL interpreter shortages and procurement, but maintains the government's preference for industry self-regulation. The Minister will raise these issues with the BSL Advisory …
Responded
Gareth Johnson
Concerns: Deteriorating hospital infrastructure and critical care capacity issues pose a significant risk, as safeguards against moving critically ill patients may fail under pressure.
Responded
[REDACTED]
Concerns: There were widespread failures in the quality, accuracy, and auditing of patient observations, including staff distraction during crucial monitoring. Concerns also persist regarding the door-locking system's reliability and staff guidance for its failure.
Response: The East London NHS Foundation Trust states that no further action is required for most concerns due to significant work already undertaken since the patient's death, which has resulted in …
Responded
Gabriella Jaiyesimi
Concerns: Tesco staff, including duty managers, lacked basic first aid and CPR training, resulting in a failure to recognize cardiac arrest, perform life-saving actions, or effectively communicate crucial information to emergency services.
Responded
Jessica Smithson
Concerns: The delayed rollout of national 24/7 crisis text services leaves a critical gap, with charities filling the void inconsistently, leading to varied support, challenges in police response, and limited integration with NHS mental health pathways.
Responded
Jean Dye
Concerns: An unexplained Emergency Power Off (EPO) circuit activation caused a critical power loss during an emergency procedure, with no in-lab indicators or reset, significantly delaying treatment and highlighting a guidance gap.
Responded
George Fraser
Concerns: The Mental Health and Wellness Team failed to establish a clear care plan or robust risk assessment. They also neglected to act on concerns about patient contact, delaying risk review and family notification.
Responded
Eleanor Curley-Bennett
Concerns: There was a critical lack of availability of essential medical equipment and adrenaline, which severely compromised the ability to provide emergency care.
Responded
Jean Langan
Concerns: The absence of a real-time database for hospital helicopter landing sites and a lack of readily available manager contact details present significant risks to safe helicopter operations.
Responded
Nonie Atshiki
Concerns: Hostel night staff lacked essential first aid, CPR, and naloxone training, and the facility did not have a defibrillator, compromising emergency response capabilities for residents.
Responded
Karen Dack
Concerns: Repeated last-minute surgery cancellations are occurring due to insufficient theatre capacity. Despite prioritization reviews, a lack of theatre expansion means this systemic issue risks future deaths.
Responded
Elton Deutekom
Concerns: A newly qualified midwife was distracted by administrative tasks, missing critical CTG changes. The obstetric registrar failed to identify acute hypoxic injury due to reliance on historic data, and senior staff delayed emergency response despite prolonged abnormal CTG.
Overdue
Dean Bray
Concerns: Staff in seclusion rooms could not make emergency calls directly, and paramedics faced delays accessing a patient due to unknown and unshared direct ward access routes, hindering emergency response.
Overdue
Emily Lewis
Concerns: Inconsistent regulations for high-speed RIB operations, inadequate craft design for passenger safety, poor forward visibility, and insufficient risk management systems contribute to serious impact and vibration injuries. Licensing arrangements and interim safety measures are needed.
Responded
Andrew Howat
Concerns: A taxi firm's training on driver duty of care and safety protocols for vulnerable passengers is inadequate, as a driver would repeat leaving a passenger in an unsafe location and police contact protocols were not followed.
Responded
Vera Spencer
Concerns: Low ambulance service categorisation of falls leads to dangerously long waits for elderly patients, increasing risks of serious complications like pneumonia and pressure damage, exacerbated by the absence of an out-of-hours falls service.
Responded
Margaret Aitchison
Concerns: A critical failure exists in care home fire safety, as staff lack formal systems and training for checking residents after fire alarm activations, despite management claims of improvements.
Responded
Felix Hartley
Concerns: Neonatology Consultants are not immediately on-site overnight or weekends at two distant hospitals, and variable response times due to travel constraints pose a risk in emergencies.
Responded
Hannah Jacobs
Concerns: Insufficient consideration for managing anaphylaxis risk during school commutes highlights a need for better education for schools, patients, and parents on the importance of carrying adrenaline auto-injectors.
Overdue
Daphne Austin
Concerns: Insufficient contingency planning during industrial action led to inadequate medical cover, with one consultant managing 25 patients and the deceased receiving no medical input on a strike day.
Responded
Lucas Pollard
Concerns: A Critical Care Team was not immediately dispatched, and an End Of Shift Policy was inappropriately applied, preventing a rapid response vehicle deployment, despite clear evidence of patient deterioration.
Responded
Thomas Langley
Concerns: Travelodge hotels lack 24-hour availability of fully trained first aid staff, and all employees lack comprehensive basic first aid training, posing a risk during emergencies.
Responded
REDACTED
Concerns: There were concerning delays in the London Fire Brigade's response, specifically in deploying an extended height ladder appliance, to a person on a block of flats roof.
Responded
Nadia Wyatt
Concerns: Failures in care planning included incomplete patient records, lack of bespoke care plans with "cutting and pasting," inadequate risk assessments, and an over-reliance on the patient's carer.
Responded
David Moore
Concerns: A patient's tracheostomy tube became dislodged, leading to delayed replacement and subsequent hypoxic cardiac arrest, indicating a critical failure in medical management.
Overdue
Claire Homer
Concerns: The absence of robust protocols for managing patient deterioration when key staff are on leave, or both contacts are absent, led to a critical email going unanswered, resulting in delayed care.
Responded
Graham Coombe
Concerns: Emergency access to the pier was obstructed by a locked gate and unavailable key. Additionally, life-saving rings were hidden, had insufficient rope length for low tide, and were inadequate in number.
Responded
Margaret Kelly
Concerns: Unsustainable pressure on emergency department staff, stemming from insufficient strategic planning and support, is causing treatment delays and raises concerns about patient safety and increased mortality.
Responded
Miss C
Concerns: The hospital's policy regarding the out-of-hours availability of Resuscitation Officers requires review to ensure timely emergency response.
Overdue
Benjamin McQueen
Concerns: Military diving training had critical safety shortcomings, including no spare breathing gas for standby divers, inappropriate acceleration of training, lack of readily available defibrillators, and inconsistent safety pressure guidelines.
Responded
Andrew Vizard
Concerns: Emergency response systems and staff training are inadequate, causing significant delays in obtaining monitoring, doctor attendance, and ambulance calls for patients with critical breathing concerns.
Overdue
Sean Heeney
Concerns: Bridgewood House lacked a clear plan for safely extricating medically unwell or uncooperative residents from its first floor, compounded by the building's layout, leading to dangerous delays.
Responded
Matthew Phipps
Concerns: The hospital lacked a contingency plan for providing intensive care when the unit was full, resulting in a patient requiring critical care not being admitted.
Overdue
Dorothy Jones
Concerns: Ongoing insufficient ambulance resources in Gwent consistently result in unacceptable response times for Amber 1 patients, with chronological allocation lacking clinical consideration and ad hoc interventions not supported by policy.
Responded
John Fallon
Concerns: Care homes lack routine speech and language therapy assessments for denture changes, leading to unsuitable diets and increased choking risk due to delayed dental services. Furthermore, care homes do not routinely have suction machines for choking emergencies.
Responded
Levi Alleyne
Concerns: Ambulance operators lacked clear procedures and accessible contact information for electricity distributors during electrical hazards, leading to significant delays in cutting power. This confusion risked both bystander and emergency service safety and delayed life-saving treatment.
Overdue
Charles Evans
Concerns: The care home exhibited multiple critical safety failures including no CPR-trained staff, lack of emergency procedures or equipment, inadequate resident supervision during meals, and absence of post-hospital admission risk assessments.
Overdue
John Heffron
Concerns: Significant delays occurred in making a crash call and initiating CPR for a patient who suffered cardiac arrest in A&E, due to initial misidentification of death and confusion regarding DNAR status.
Responded
Keith Holmes
Concerns: Unmaintained electrical equipment during the COVID-19 pandemic increased fire risks, exacerbated by a failure to reassess these dangers and a lack of contingency planning for future lockdown scenarios.
Responded
Ashleigh Timms
Concerns: Fire safety failures included incompetent staff, non-compliant fire alarms without automatic emergency service links, unfit policies, flawed audits, and dangerous keypad locks on exit doors.
Responded
Laura Smallwood
Concerns: The absence of a single 'Event Organiser' for public events hinders safety planning and risk management, as authorities lack legal powers to mandate an organiser or refuse unsafe events.
Responded
Brendan Eccles
Concerns: Volatile organic compounds within a pontoon created an easily flammable environment when exposed to external heat, posing a significant explosion risk.
Overdue
Neil Stewart
Concerns: There was an absence of clear, written safety policies and protocols for venues and event providers, leading to inadequate communication of risks and poorly defined responsibilities for guests.
Overdue
Daniel Rennoldson
Concerns: The Trust lacked contingency for multiple urgent responses, leaving callers at risk, and had a 12-hour delay in following up a high-risk call with no tracking mechanism for unprogressed cases.
Responded
Leonard Pritchard
Concerns: The emergency department has an inadequate supply of mobility aids for patient assessments, posing a significant risk, and the procurement process for these essential aids is unmanaged and delayed.
Responded
Guy Paget
Concerns: The prison lacked an efficient, tested system for emergency ambulance exit, leading to delays in transferring a seriously ill prisoner to hospital.
Responded
Richard Dyson and Simon Midgley
Concerns: Hotels lack readily accessible and accurate guest/staff lists for emergency services, leading to critical delays in rescue efforts due to time lost establishing who was missing.
Overdue
Mohammed Zeb
Concerns: A critical lack of accessible water rescue aids, including flotation devices or throw lines, at the incident scene hindered efforts to save a non-swimmer.
Overdue
Joe Robinson
Concerns: Police were unable to prevent a large, illegal gathering with no safety provisions, and concerns remain about whether lessons learned regarding policing such events have been effectively shared.
Overdue
Brian Button
Concerns: The concerns text provided is incomplete and does not specify any particular safety issues or systemic failures.
Responded
Cheralyn Clulow
Concerns: Police lacked appropriate fire drop keys and training for emergency access to communal properties, causing delays in attending a deceased person's address.
Responded
Rory Attwood
Concerns: The patient fell between gaps in primary, acute, psychiatric, and social services. GPs are rarely involved in serious incident reviews, which limits learning and partnership working for community-supervised patients.
Responded
Thomas Rawnsley
Concerns: Virtual consultations risk misunderstanding due to lack of written follow-up. Inconsistent initial questioning across emergency services leads to incomplete clinical triage, and paramedic patient leaflet information is often inaccurate.
Responded
Andrew Westlake
Concerns: Airline staff lacked policy and training for identifying and safeguarding mentally unwell, vulnerable passengers, leading to disembarkation without support in a foreign country.
Responded
Alyn Rees
Concerns: Excessive ambulance waiting times (2 hours) without informing the family of estimated arrival, coupled with significant hospital patient transfer delays, prevented ambulances from being released for other emergencies.
Overdue
Anthony Williamson
Concerns: Concerns persist regarding reduced coastguard and lifeguard cover on the Cornish coastline, with no transparent, published plan on mitigation strategies or current service levels available to the public.
Responded
Jan Klempar
Concerns: Reduced lifeguard cover on Cornish beaches lacks a clear, publicly available plan detailing coverage levels or how shortfalls will be mitigated by other emergency services, increasing safety risks for bathers.
Responded
Gillian Davey
Concerns: The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for resuming this essential service leaves the public vulnerable.
Responded
Michael Pender
Concerns: The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for resuming this essential service leaves the public vulnerable.
Responded
Thomas Reilly
Concerns: The lack of a formal, structured intervention system at suicide hotspots, relying on ad-hoc approaches, raises concerns about consistent prevention of self-harm.
Overdue
Maureen Waterfall
Concerns: There is no licensed antidote for Edoxaban anticoagulant, increasing risks for head injury patients. Concerns were raised about the lack of national guidance on antidote administration targets and storage, especially for non-tertiary hospitals.
Overdue
Henry Campbell-Byatt
Concerns: The resort lacked essential deep-water rescue equipment and trained staff. The system for monitoring swimmers was inadequate, necessitating improved watchtower manning and safety equipment.
Overdue
Evha Jannath
Concerns: The ride suffered from inadequate CCTV monitoring due to staffing issues, lack of clear safety warnings to guests, poor signage, and no staff training or equipment for water rescue, alongside unclear emergency procedures.
Overdue
Cesar Gonzalez Barron
Concerns: Multiple failures in event first aid included delayed recognition of collapse, inadequate first aider briefing and knowledge of venue protocols, poor communication, and a chaotic scene that delayed CPR and ambulance access.
Overdue
Blaithin Buckley
Concerns: An unexplained delay occurred in calling an ambulance to transfer a patient from a mental health setting during a medical emergency, with unclear policies regarding ambulance activation.
Responded
William Oliver
Concerns: The ambulance service's rigid meal break policy reduced vehicle availability during peak demand, compounded by excessive hospital turnaround times, leading to significant delays.
Responded
Gladys Furnival
Concerns: The ambulance service lacks a protocol to engage other emergency services for assistance or updates during significant delays when there is no direct observation of the scene.
Overdue
Karen Burns
Concerns: Police resources are critically insufficient, leading to incorrect call grading and leaving numerous P2 and P3 calls unanswered due to high demand for priority incidents.
Responded
Lucy Lee
Concerns: A lack of mandatory national training for Firearms Enquiry Officers and systemic flaws in assessing medical fitness of shotgun certificate applicants, including undeclared conditions and inadequate FEO skills, create risks.
Overdue
Priscilla Tropp
Concerns: The station lacked a clear flow chart or plan to guide staff on appropriate steps to take when a person falls ill, risking further injury.
Responded
Scott Marsden
Concerns: The absence of a defibrillator at Marshalls Arts College poses a critical safety concern.
Overdue
Michael Davies
Concerns: The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.
Responded
Wayne Rodgers
Concerns: Ambulance services are overstretched, and major event safety planning is insufficient. Deficiencies include lack of on-site medical provision, inadequate crisis management, and unclear safety equipment requirements and racing abandonment criteria.
Responded
Tony Goodridge
Concerns: The property lacked a smoke alarm. Emergency services faced difficulty accessing the property due to parked vehicles, hindering response.
Overdue
Simon Robinson
Concerns: The current partnership agreement inadequately addresses mental health crises in private places, creating a gap in effective agency response where police powers are limited despite their primary responsibility.
Responded
Jeremy Sutch
Concerns: Medical evacuation was severely delayed by crew unfamiliarity with a wheelchair extraction stretcher, its incompatibility with ship equipment, and lack of evacuation drills, posing a risk for future survivable injuries.
Overdue
Christopher Seal
Concerns: Multiple failures in information sharing, record keeping (RIO system), and lack of "no response" or "welfare check" policies in primary care, exacerbated by staff training issues and limited communication options.
Responded
Alexandre Parr
Concerns: The provided text is incomplete and does not detail any specific concerns regarding future deaths.
Responded
Dorina Zangari
Concerns: Undermined fire safety measures, absent functioning fire detection, and an inadequate alternative escape route in maisonettes place residents at significant risk of death or injury from fire.
Overdue
Kurt Cochran; Leslie Rhodes; Aysha Frade; Andreea Cristea; PC Keith Palmer.
Concerns: A Prevention of Future Deaths report was issued to multiple authorities following the Westminster terror attack to address systemic issues related to such events.
Responded
Jack Riding
Concerns: There were significant delays in defibrillator deployment and ambulance access due to equipment placement, lack of staff direction, and insufficient emergency training, coupled with inadequate medical emergency risk assessments.
Overdue
John Graham
Concerns: Lack of routine installation of carbon monoxide detectors in residential accommodation rented by Rochdale Borough Housing Limited creates a risk of future deaths.
Responded
Ryan Williams
Concerns: Unsupervised, unmanned stations pose a risk, as vulnerable individuals can remain on premises for extended periods without any oversight or means of intervention.
Overdue
Catherine Gibbon
Concerns: Significant safety failures included inadequate health pledge guidance, untrained staff for medical conditions, insufficient CCTV monitoring with a broken camera, lack of emergency alarms/communication, and lapsed first aid certifications at the gym.
Overdue
Joshua Edwards
Concerns: Ambulance response was delayed by public event road closures and unclear authority for crews to cross them. Event organizers need to brief staff and public on emergency vehicle priority.
Responded
Abigail Hall
Concerns: The continued absence of a defibrillator and first aid trained staff at the premises creates a critical risk for emergency medical response in critical situations.
Responded
Patricia Cragg
Concerns: The radiology department lacked sufficient CT resources and staff for simultaneous emergencies, causing reporting delays, and had no internal major incident policy to guide responses.
Responded
Kamal Al-Hirsi
Concerns: Dangerous pool cleaning methods, inadequate staff water safety training, ineffective panic alarm systems, and flawed emergency communication protocols highlight significant safety failures at the facility.
Responded
Yunis Hadi
Concerns: A lack of formal first aid training, including choking response, for volunteers, absence of emergency medical equipment, and insufficient oversight for child safeguarding were identified.
Responded
Ashley Notson
Concerns: There is no legal requirement for care home carers to have first aid training or to carry mobile phones, posing a risk in emergency situations.
Overdue
Samuel Clarke
Concerns: Site security was inadequate, with an accessible turnstile allowing unauthorised entry, and a lack of contingency plans or improved equipment for security officers.
Responded
Andrew Crane
Concerns: Unclear guidance for prison officers on initiating emergency calls for chest pain, and failure to update ambulance services with critical changes in patient condition, compromised emergency response.
Overdue
Philip Ashton
Concerns: Medication errors occurred due to flawed procedures, staff were unprepared for emergencies, and vital medical history was inaccessible to ambulance crews.
Overdue
Gustavo Da Cruz, Mohit Dupar, Inthushan Sriskantharasa, Gurushanth Srithavarajah, Kenugen Saththiyanathan, Kobikanthan Saththiyanathan and Nitharsan Ravi
Concerns: There is a lack of formal governance and risk management for beach safety. A national review of safety regimes and potential government powers to restrict beach access is needed.
Responded
Sousse (Tunisia)
Concerns: Travel companies lacked board-level security advisors and failed to prominently display government travel advice, leaving customers potentially uninformed about terrorism risks in destination countries.
Overdue
Patrick Woods
Concerns: The hospital's unknown equipment portfolio prevented the identification of potentially dangerous devices, hindering proper risk assessments and actions to prevent patient injury or fatalities.
Responded
Russell Sherwood
Concerns: The Fire Service departed a dangerous flood scene without closing the road or leaving warning signs, as their protocols and equipment do not permit road closures, relying solely on other authorities.
Responded
William Wilson
Concerns: The establishment lacked a clear system for alerting the designated first aider, and staff who attended the deceased were unfamiliar with basic life-saving first aid techniques.
Overdue