Vulnerable people fire risk
Failure of social services and housing providers to proactively assess fire risks, identify vulnerable individuals, and implement preventative measures.
69 items
7 sources
3 inquiries
Source spread
Where this theme appears
Vulnerable people fire risk has been flagged across 7 independent accountability sources:
9 inquiry recs
33 PFD reports
3 committee recs
1 CQC action
1 PPO rec
2 IMB recs
20 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (9)
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
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
FENN-65 — Ban the sale of smokers' materials at all Underground stations
Recommendation: The sale of smokers' materials at Underground stations shall be banned.
Unknown
RONA-22 — Review regulations for storing explosive materials in high-rise residential blocks
Recommendation: The Regulations governing the storage of other potentially explosive materials in high blocks of flats should be reviewed {paragraph 173}.
Unknown
P2-10 — Require fire safety strategy from registered fire engineer at Gateway 2
Recommendation: That it be made a statutory requirement that a fire safety strategy produced by a registered fire engineer to be submitted with building control applications (at Gateway 2) for the construction or refurbishment of any higher-risk building and for it …
Gov response: The government accepts this recommendation. A fire safety strategy is already required with building control applications for the construction of and significant work to higher-risk buildings. The Building Safety Regulator will consider how to make …
Accepted
In progress
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
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
FENN-64 — Encourage non-smoking with warnings and provide stubbing bins at entrances
Recommendation: By audible and visual warnings London Underground must encourage passengers not to smoke. Stubbing bins shall be provided at station entrances.
Unknown
FENN-63 — Extend smoking prohibition to all underground station areas, including staff and shops
Recommendation: The present prohibition on smoking shall be extended to all areas of stations wholly or partly below ground, including staff accommodation and shops.
Unknown
PFD Reports (33)
Vera Lillian Steel
Concerns: A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons or smocks to residents who smoke to prevent similar incidents.
Overdue
Betty Grace Payne
Concerns: Insufficient information sharing about vulnerable individuals with the Fire Service and a lack of training for Local Authority staff on home fire safety checks increase fire risks for the elderly.
Overdue
Julie Ann Camm
Concerns: A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing to ensure installation and increasing the risk of death from fire.
Response (Leeds City Council): Housing Leeds will install hard-wired smoke detection in 40 properties and battery-powered detectors in remaining properties without detection equipment over the next 12 months, in consultation with West Yorkshire Fire …
Responded
Alfred Hodges
Concerns: Conwy's Telecare package lacks standard interlinked smoke alarms, and interim safety provisions are unclear. Additionally, the deceased was not offered a free home fire safety check.
Response (Conway): The council has installed 105 linked smoke detectors, funded a full-time installation post, and received refresher training from NWFRS on smoke detector placement. They also prepared a briefing note for …
Responded
Sidney Harvey
Concerns: Non-safety glass doors in rented properties, particularly where vulnerable individuals reside, pose a risk, and there is no clear system for their replacement or safety upgrade.
Overdue
Anne Fowler
Concerns: Smoke alarm covers were left in place after installation, making them inaccessible and ineffective. Legislation should require their removal by builders or landlords prior to occupation.
Overdue
John Hills
Concerns: Paraffin-based emollient creams lacked fire hazard warnings on labels and prescriptions, and risks were not communicated to a known smoker, highlighting a gap in NPSA guidance for lower percentage creams.
Overdue
Emma Waring
Concerns: The absence of compulsory automatic water suppression systems in residential properties, especially for vulnerable individuals, represents a significant fire safety risk.
Response (RBH): Rochdale Boroughwide Housing has delivered domestic sprinklers in properties occupied by some of their most vulnerable tenants and is working with Rochdale Council’s Strategic Housing Service on a project designed …
Responded
William Thompson
Concerns: A high-risk service user lacked a smoke detector in his bedroom; social workers failed to assess or address this significant fire safety risk.
Response (William Thompson): The Hackney Safeguarding Adults Board commissioned a Safeguarding Adults Review under the provisions of the Care Act 2014, which has twenty six recommendations for improving practice and procedures across all …
Responded
Sadie Peters, Joseph Peters and George Peters
Concerns: Inadequate awareness programmes exist for the importance of fitting and maintaining smoke detectors in mobile and static caravans, increasing fire safety risks.
Response (Peters): The Caravan Club will include a reminder of fire safety, specifically the need for smoke detectors, in their monthly members' magazine and other publications.
Response (Surrey Fire and Rescue Service): Surrey Fire and Rescue Service, working with partners, has visited identified mobile home sites in Surrey, conducting fire safety visits and fitting smoke and carbon monoxide alarms. They are planning …
Overdue
Sharon Soares
Concerns: There have been multiple fatalities and numerous accidental injuries linked to Bio Ethanol burners, indicating an ongoing and significant product safety risk.
Overdue
Brian MaClean
Concerns: Social Services and housing providers failed to proactively assess fire risks, make referrals to fire services, or install automatic water suppression systems and appropriate alarms for high-risk individuals.
Response (Manchester City Council): In response to concerns, Manchester City Council has reviewed closed contacts, is undertaking an audit of 'No Further Action' cases, will provide further training for Contact Centre staff, will have …
Overdue
Jac Davies
Concerns: Landlords in Wales are under no legal obligation to install smoke alarms in rented properties, contrasting with England's regulations, and current "best practice" recommendations carry no enforcement.
Response: The Welsh Government is drafting regulations under the Renting Homes (Wales) Act 2016 that will place a legal duty on both social and private landlords to fit smoke and carbon …
Responded
Ian Leak
Concerns: The communal fire alarm system at Honiton Oaks failed to trigger audible alerts within individual flats, raising serious safety concerns for residents, particularly those with mobility problems under a "Stay Put" policy.
Response (Peak Valley Housiing Asscoiation): The housing association is installing combined heat and smoke detectors in residents' flats, linked to a main system with external monitoring, commencing in October 2017. They have also commenced a …
Overdue
Kevin Freely
Concerns: Insufficient awareness and adherence to fire safety warnings regarding paraffin-based emollients, smoking in bed, and air-flow mattresses, combined with inadequate risk assessments, pose significant fire risks.
Overdue
Brian Bicat
Concerns: Inadequate fire hazard warnings on paraffin-based emollient packaging, insufficient awareness among healthcare professionals and the public, and inconsistent prescribing system alerts pose significant fire risks.
Response (Bradford District Care NHS Trust): Bradford District Care NHS Foundation Trust has produced a safety information leaflet and fire hazard poster for patients using paraffin-based products. An alert has been created on the clinical records …
Response (Alliance Pharmaceuticals and Bayer): Alliance Pharmaceuticals has completed a product labelling review to improve prominence, clarity, and content related to fire hazards of Hydromol, with revised labeling expected throughout 2018 and 2019. Bayer is …
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA is reviewing evidence and has convened an expert group to advise on regulatory action for paraffin-containing medicines and devices, considering coroners' reports and other data. They will provide …
Overdue
Mihaela Lazar
Concerns: Inadequate fire detection and warning systems, including missing smoke alarms and kitchen doors, combined with unacceptable escape routes in older maisonettes, pose a significant fire risk in thousands of properties.
Overdue
Tony Goodridge
Concerns: The property lacked a smoke alarm. Emergency services faced difficulty accessing the property due to parked vehicles, hindering response.
Overdue
Christopher Hart
Concerns: The housing provider failed to impose fire safety standards for tenant furniture and did not review sprinkler system installation, despite evidence of their life-saving potential.
Response (Johnnie Johnson Housing): Johnnie Johnson Housing notes the comments regarding resident safety but states no further action is required as the property was built to standard in 1999 and no high risk was …
Responded
Riley Holt, Keegan Unitt, Tilly-Rose Unitt and Olly Unitt
Concerns: Conventional smoke alarms may be ineffective for children under 16, particularly boys, suggesting mandatory fire suppression systems in all new properties, similar to Wales, should be considered.
Response (Ministry of Housing, Communities and Local Government): The Secretary of State acknowledges the deaths and states that the government is committed to building safety, including a review of smoke alarm standards.
Responded
Neil Barre
Concerns: Communication between Staffordshire Fire and Rescue Service and domiciliary care providers needs improvement to ensure awareness when clients are not using provided fire safety equipment.
Response (Staffordshire Fire and Rescue Service): Staffordshire Fire and Rescue Service will conduct a fatal fire review involving key partner agencies, sharing any multi-agency learning. The learning will be used to review prevention and partnership activity, …
Responded
Sylvia Griffiths
Concerns: Consideration should be given to fire and smoke alarms specifically designed for people with dementia, which could improve safety for this vulnerable group.
Response (Staffordshire Fire and Rescue Service): Staffordshire Fire and Rescue Service will conduct a fatal fire review of the case with partner agencies, share learning nationally, and incorporate findings into Olive Branch training sessions.
Responded
Henry Boddy
Concerns: There is a gap in enforcement powers regarding fire risks in residential properties, specifically the risks of a fire load arising from hoarding behaviour.
Response (Home Office): The Home Office acknowledges concerns about fire risks from hoarding but suggests a multi-agency approach is more appropriate than enforcement under the Fire Safety Order. They highlight the role of …
Overdue
James Golds
Concerns: Inadequate guidance exists for managing fire risk in supported accommodation for vulnerable residents, exacerbated by no statutory sprinkler requirement and ineffective smoke detector placement.
Response (Department for Levelling Up Housing Communities): The Department for Levelling Up, Housing & Communities references existing building regulations, guidance, and the role of fire and rescue authorities, but does not commit to further action.
Responded
Daphne Holloway and Ivy Spriggs
Concerns: Sprinkler systems are not mandatory for care homes with residents of limited mobility, and these buildings aren't classified as 'Higher Risk Buildings' based on occupant vulnerability, leaving them at elevated fire risk.
Overdue
Saima Usman
Concerns: Privately rented accommodation in Wandsworth is at increased fire and CO risk due to the lack of mandatory smoke/CO detectors, as the borough has no registered landlord scheme or enforcement powers.
Overdue
Reginald Cauthery
Concerns: A vulnerable person's telecare service was not reviewed despite increased fire risk, and smoke alarms were not connected to telecare, delaying emergency fire brigade notification.
Response (TEC Services Association): The TEC Services Association (TSA) will issue guidance to certified monitoring organizations by the end of November 2022. They also plan to develop a Fire Call Handling Pathway Decision Support …
Response (Home Care Quality Commission): The CQC acknowledges the concerns but states they relate to services outside their scope of regulation (fire service and telecare service) and therefore they have no powers to prevent future …
Response (Department of Health and Social Care): The Department of Health and Social Care has reminded local authorities to consider technology-enabled care in maintaining independence and linking preventative devices like smoke detectors. It also published an updated …
Response (Home Office): The Home Office will share information from the case with the National Fire Chiefs Council (NFCC) and encourage them to disseminate findings and highlight the importance of linking telecare systems …
Response (UK Telehealthcare): The organisation recommends monitored smoke detectors and rapid heat detectors for elderly and vulnerable service users, referencing recommendations made with London Fire Brigade in 2003.
Response (Lodon Borough of Hackney): The London Borough of Hackney will address its procedures and guidance within its 'Mosaic' system to reduce risks to vulnerable individuals, especially regarding fire safety for those with risk factors …
Responded
Brian Harfield
Concerns: There's a critical lack of compulsory fire safety provisions, such as sprinklers, in extra care facilities for vulnerable, immobile residents, leaving them at significant risk of death from fires.
Response (Department for Levelling Up Housing and Communities): The Department for Levelling Up, Housing and Communities acknowledges the concerns regarding fire safety measures in extra care facilities and outlines existing regulations, guidance, and the role of the Building …
Responded
Christopher Evans
Concerns: A deficiency in the regulatory framework means vulnerable persons in supported HMOs are not protected from scalding risks, as no regulatory body assesses or requires thermostatic controls, unlike other health and social care settings.
Overdue
Paul Keating
Concerns: The local authority lacked statutory power to install sprinkler systems in private flats without consent, leading to one resident's flat remaining unconnected, which likely contributed to his fire-related death.
Response (Leeds City Council): Leeds City Council acknowledges the coroner's concerns regarding a lack of legal powers to access properties for safety works without tenant consent. The council states that granting additional legal powers …
Response (Home Office): The Home Office acknowledges the coroner's concerns about fire risks in social housing but explains the existing regulatory framework, including the Regulatory Reform (Fire Safety) Order 2005 and the Housing …
Responded
Gabrielle Steel
Concerns: Critical fire safety assessment findings were not communicated by the London Fire Brigade to carers or family, preventing the implementation of a vital risk management plan for a vulnerable individual.
Response (London Fire Brigade): The London Fire Brigade is reviewing its processes for sharing home fire safety visit findings with third parties, consulting the Information Commissioner regarding data protection issues, and reviewing questions asked …
Response (Newham Council): The London Borough of Newham will hold a reflective case discussion at the Fire Safety Group, improve training for social care staff on fire safety risk assessment, produce a '7 …
Responded
Liam Allan
Concerns: Inadequate visibility of riverside buoyancy aids and slow, telephone-based police-to-fire service communication create critical delays in emergency response, increasing drowning risks.
Response (London Fire Brigade): The London Fire Brigade has made significant changes to its radio system following the Grenfell Tower Inquiry, improving communication interoperability. They have also installed throwline boards, provided throwline training to …
Response (National Fire Chiefs Council): The National Fire Chiefs Council highlights the Fire Control Fire Standard and Guidance, the Multi-Agency Information Transfer (MAIT) system, and ongoing liaison with London Fire Brigade to ensure learning is …
Response (London Borough of Barking and Dagenham): The London Borough of Barking and Dagenham will undertake a survey and asset mapping of waterbodies and riverside locations, assess sites using risk assessment criteria, standardise safety equipment, and implement …
Response (London Borough of Havering): The London Borough of Havering will give further consideration to the lighting of life buoys at inland bodies of water, ensure new buoyancy aids meet British Standards and require white …
Response (City of London): The City of London acknowledges the concerns raised. The text describes various procedures and resources in place for managing incidents and ensuring safety, without stating a change in policy.
Responded
Jacqueline Joseph
Concerns: The housing association property had two incorrectly installed battery-operated smoke alarms, posing a fire safety risk.
Responded
Committee Recommendations (3)
#16 —
Recommendation: We recommend that the Government specify in the Bill itself by way of a requirement to “have regard” the factors that must be considered in the future when the scope of the regime is expanded and that the ability of …
Gov response: 40. The Government welcomes the Committee’s recognition that other factors may be suitable when exploring the future expansion of the definition of “higher-risk buildings”. While Government agrees there is a limit to the types of …
Under Consideration
#15 —
Recommendation: On balance, we consider the initial definition of “higher-risk building” proposed by the Government to be reasonable and practical, though we agree with the evidence calling for the scope to be widened in the future to include a great number …
Gov response: 40. The Government welcomes the Committee’s recognition that other factors may be suitable when exploring the future expansion of the definition of “higher-risk buildings”. While Government agrees there is a limit to the types of …
Under Consideration
#9 —
Recommendation: We agree with our witnesses that housing disrepair, particularly damp and mould, is often aggravated by the inability of tenants to heat or ventilate their homes properly or by overcrowding, or by a mixture of both. We also agree that …
Gov response: We agree with the Committee that the sector needs to ensure it prioritises the quality of housing being provided to tenants. Every tenant deserves to live in a safe, decent, and good quality home. It’s …
Not Addressed
IMB Recommendations (2)
Bure (2025)
The Governor should ensure adequate heating is provided in Residential Unit 7, especially for elderly and vulnerable prisoners, and resolve the ongoing issue with the heating system.
Governor / Director
Styal (2021)
There is a significant fire risk to prisoners who reside in the 16 houses which have not yet been refurbished at Styal. A recent survey has classed all of these buildings as red fire risk. These risks include the existence of false ceilings, and ceilings made of lath and plaster, which would require expensive and specialist repair to be brought …
Ministry of Justice
LGO / SPSO Decisions (20)
22-004-363 — London Borough of Newham
Summary: Mr Y complained about the way the Council dealt with his request that it recall two outstanding penalty charge notice debts from its enforcement agents because he is a vulnerable person. We found fault in how the Council considered his request. But this fault did not cause Mr Y …
LGO (Local Government & …
Transport And Highways
Upheld
Nov 2022
PSOW-202310243 — Swansea Council
Ms K complained that Swansea Council failed to issue a response to her complaint, which she made to it in October 2023. The Ombudsman found that whilst the Council had logged Ms K’s concerns as a Stage 1 complaint, it had failed to provide a complaint response. She said that …
PSOW (Public Services Om…
Local Government
Apr 2024
PSOW-202400091 — Pobl
Ms X complained that Pobl had failed to deal with her complaints about damp and mould in her property or to update her. The Ombudsman found that there had been a delay in Pobl dealing with Ms X’s complaint and it had not updated her, although after the Ombudsman approached …
PSOW (Public Services Om…
Apr 2024
PSOW-202406351 — Cardiff Council
Ms A complained that she was unhappy with Cardiff Council’s (“the Council”) actions in respect of housing repairs to her property. The Ombudsman decided that although the Council was undertaking works to resolve Ms A’s concerns, the issues had been ongoing for some time. Further, the Council had recently undertaken …
PSOW (Public Services Om…
Local Government
Jan 2025
PSOW-202407199 — Bron Afon Community Housing Ltd
Miss B complained that Bron Afon Community Housing Ltd had failed to address her concerns regarding the damp in her property and the repairs needed. The Ombudsman found that the Housing Association had not addressed Miss B’s concerns through the complaints procedure despite her making numerous calls to the Housing …
PSOW (Public Services Om…
Housing
Jan 2025
PSOW-202407682 — Newport City Homes
Miss A complained that Newport City Homes (“the Housing Association”) failed to address issues including vermin, damp and heating at her home, which had been ongoing since September 2023. Windows would not lock and repairs to pipework, undertaken following flooding at the property, were not completed properly. Miss A was …
PSOW (Public Services Om…
Jan 2025
PSOW-202005732 — Merthyr Tydfil Housing Association Ltd
Miss X complained that repair work to various issues in her home had been ongoing and unfinished since 2019,and that when repairs were carried out, they were not sufficient and the problems re-occurred and she felt that they were just temporary fixes. In considering the complaint, I was concerned about …
PSOW (Public Services Om…
Housing
Apr 2021
PSOW-202004981 — Swansea Council
Dr S complained that he was experiencing damp issues following repairs to the neighbouring Council property and that the Council were slow in responding to the matter and his complaint. The repair works have since been completed. ER – Council to apologise and explain the reasons for the delay and …
PSOW (Public Services Om…
Local Government
Apr 2021
PSOW-202101737 — Hafod Housing Association
Miss X complained that Hafod Housing Association had not provided a response or explanation to address her concerns about the damage caused to her grandmother’s property resulting in a gas leak at her property. The Ombudsman decided that the Authority should provide a written response to Miss X to provide …
PSOW (Public Services Om…
Housing
Jun 2021
PSOW-202006074 — Bron Afon Community Housing Ltd
Ms X complained that Bron Afon Community Housing (“the Housing Association”) failed to carry out repairs to her home. She stated that she had experienced problems for a number of years. The Ombudsman noted Ms X’s concerns and asked the Housing Association to carry out action in resolution of the …
PSOW (Public Services Om…
Housing
Jun 2021
PSOW-202100009 — Tai Tarian
Mr X complained about issues in relation to a boundary wall between his property and a neighbouring property that is owned by the Association. In considering the complaint, the Ombudsman was concerned that Mr X had been inconvenienced by the Association’s actions. The Association advised that they had previously dealt …
PSOW (Public Services Om…
Jun 2021
PSOW-202100196 — Monmouthshire Housing Association
Mr X’s main complaint was that the Monmouthshire Housing Association (“the Housing Association”) delayed in identifying and remedying a wood worm infestation at his property. The Ombudsman found that the problem had been ongoing for over 18 months for several reasons beyond Mr X’s control. The Ombudsman also found evidence …
PSOW (Public Services Om…
Housing
Jun 2021
PSOW-202100392 — Cynon Taf Community Housing Group
Miss Y complained that Cynon Taf Housing Group (“the Housing Association”) failed to carry out works to her property which it had previously agreed. She explained that she suffered with medical conditions and the damp, cold and mouldy conditions of the property caused her health to deteriorate. The Ombudsman decided …
PSOW (Public Services Om…
Housing
Jun 2021
PSOW-202006116 — Swansea Council
Mr A complained that since the Council had carried out work and renewed parts of the heating system in his home, it had become noisy and did not maintain the temperature level of heat that he had previously received. An assessment of Mr A’s complaint found that the Council had …
PSOW (Public Services Om…
Local Government
Jun 2021
PSOW-202101940 — Swansea Council
Mr X complained to the Ombudsman about damage that was caused to his property as a result of a leak which occurred from the property above his. The Council’s insurers refused his claim for compensation on the basis that no negligence existed. In considering the complaint, the Ombudsman noted that …
PSOW (Public Services Om…
Local Government
Jul 2021
PSOW-202402960 — Trivallis
Mr B complained about the way the housing association Trivallis (“the Association”) dealt with reports of repairs at his home. The Ombudsman investigated whether the Association responded appropriately to reports of damp and mould and a broken boiler. The investigation found that the Association did not respond appropriately to reports …
PSOW (Public Services Om…
Oct 2025
PSOW-202405250 — Trivallis
Mrs C complained about whether Trivallis (“the Association”) responded appropriately to reports of damp and mould made by her between November 2023 and the present time. The investigation found that the Association did not always respond appropriately to reports of damp and mould. Reports of issues in Mrs C’s home …
PSOW (Public Services Om…
Oct 2025
PSOW-202503002 — Cardiff Council
Mr A complained about mould and damp in his property, and the cleaning of his windows. The Ombudsman recognised that whilst Cardiff Council (“the Council”) had taken steps to alleviate issues, Mr A continued to report mould and damp in his home. There was also dispute over whether the windows …
PSOW (Public Services Om…
Local Government
Oct 2025
24-010-418 — Crawley Borough Council
Summary: We will not investigate this complaint that the Council misled a tribunal and the courts. The law prevents us from investigating what happened in court or tribunal proceedings.
LGO (Local Government & …
Housing
Oct 2024
24-002-386 — Portsmouth City Council
Summary: Miss X complained the Council failed to fulfil its duties when she reported disrepair in her private rented accommodation. She also complained about a telephone call with a Council officer. We find no fault in the Council’s decision making or in the customer service provided.
LGO (Local Government & …
Housing
Not Upheld
Oct 2024