Everyone who comes into contact with people who are at increased risk of harm by fire has a duty to promote fire safety to keep them safe from fires in their home. 

The S.11 duty under the Children Act 2004, sets out that organisations and agencies should have in place arrangements that reflect the importance of safeguarding and promoting the welfare of children, including:

• A culture of listening to children and taking account of their wishes and feelings, both in individual decisions and the development of services;
• Clear whistleblowing procedures;
• Clear escalation policies;
• Established processes information sharing;
• Supervision and support to fulfil their child welfare and safeguarding responsibilities effectively;
• Safe recruitment practices; 
• A culture of safety, equality and protection within the services they provide.

To check if someone is vulnerable, ask:

• Are they at increased risk of harm by fire?

• Can they react, respond and escape? 

• If not, how can fire risks be minimised? 

When you come into contact with a vulnerable person, it is important to focus on: 

• Empowerment - supporting and encouraging the person to make their own decisions to keep themselves safe.
• Prevention - taking action to prevent harm rather than waiting for harm to occur.
• Proportionality - responding in the least intrusive way to minimise risks.
• Protection - ensuring adequate support is provided to meet individual needs. 

Partnership working - no one should work in isolation. All agencies have a part to play in preventing, detecting and reporting fire risks, and should be proactive in doing so.

Professional curiosity can help save lives.

Act on your instincts when you make a home visit. Look around, ask questions, relate these to common fire risks, and the learning from fatal fire incidents. 

Always ask questions of the lived environment. In every room, think: could a fire start here? If it did, could the person get out? Is there anything that could block escape routes? 

A recurring theme in learning from Serious Case Review is the assumption that someone else is doing something, and therefore there is no need for the individual to take action. Here are some examples from the most recent triennial analysis of SCRs:

1. Thresholds for referral and assessments

• Practitioners are at times unsure if a referral will meet the threshold for children’s services or they have experiences of cases that have not met the threshold in the past. Such experiences can make them reluctant to refer again;
• The school did not make referrals to Children Social Care, as they did not think the case would reach their threshold;
• If a case does not meet the threshold, then there is a risk that the referring agency feels reassured that the child is safe rather than continuing observing patterns of neglect or abuse, and then not refer again when there is a more serious concern;
• Children Social Care assumed that the young person was engaging with another service this was not ascertained. The SCR found that he was not engaging which left him at risk.

2. Poverty

• Practitioners can become desensitised to the impact of poverty and accept lower standards for children and families rather than assessing it from the perspective of neglect and drawing conclusions about the impact on the child e.g deprivation of food;
• Supervision can support reflective practice that would challenge such assumptions, and enable practitioners to identify poverty and work proactively with families to address its causes and consequences. 

3. Backgrounds, culture and beliefs 

• SCR commonly make the point about needing to find out about people’s backgrounds, culture and beliefs, and then apply that knowledge;
• It is about finding out what beliefs mean in practice, how this manifests in the internal world of the parent or carer and the part it plays in their identity;
• Unexplored assumptions by the professional, then found their way into assessments and plans. 

4. Lack of professional curiosity

• Gaps in practitioners ability to explore and understand what is happening within a family rather than making assumptions or accepting what is said by parents or carers at face value is a common feature in SCRs;
• The term "respectful uncertainty" is sometimes used to describe an approach which is focused on safety for children but that takes into account changing information, different perspectives and acknowledges that certainty may not be achievable.

Learning from case reviews highlight that:

• It is all too easy to assume that someone else is doing something
• This leads to assumptions that there is no need for the individual to take action. 
• Key themes about not making incorrect assumptions are around:
• Thresholds for referral and assessments 
• Poverty
• Backgrounds, culture and beliefs  
• Lack of professional curiosity

Confirm what you see and hear, for example:

• If the person or parent says they smoke, look for appropriate disposal of the cigarettes.
• If you see a smoke alarm, ask them to check that it works.
• If the person or family say they can escape a fire, ask them how and assess if it is possible. If they or their child have reduced mobility, what would escape look like? 
• If the person or family say they have a bedtime routine, ask them more specifically what it is to ensure that fire risks are fully considered. Are they checking that the gas fire has been turned off before going to bed?

Another recurring theme in learning from Serious Case Review is a lack of information sharing. It is important to always refer a concern about a person who is at increased risk of fire.

When you come into contact with a person who is of increased risk of harm by fire, consider referring to your local fire service for specialist advice on how to minimise fire risks.

If the criteria for making a safeguarding referral is met refer your concern to your local authority. If you are not sure, consult with your organisation’s safeguarding lead, or contact the Local Authority for advice.

We know that positive engagement will increase the likelihood of cooperation with people who have care and support needs. 

Taking an empowering approach also  helps build resilience, confidence, decision-making skills and independence in the person who is engaged in the risk assessment process. 

This is important to ensure that any plan that is put into place will be effective in reducing the risk of harm by fire.

Most fires start accidentally, and the best way to tackle them is prevention. It is important to understand:

• why fires start in the first place,

• where the most common fire risks are,

• what you can do to help reduce fires,

• how to identify those who are at increased risk of harm by fire, and

• when, and where to refer fire risk concerns.

The challenges facing practitioners are strongly evident in the SCRs and when practitioners are working with deeply disturbing cases, it is critical that organisations support and safeguard their staff effectively so that they can safeguard children confidently.

Key themes are: 

• • Personal challenges
  • Service changes and fractured arrangements
  • Lack of space for reflection
  • The role of debriefs and support systems
  • Multi-agency training

All organisations need to support staff or volunteers who know, and care about those who have been victims of fire incidents. There are many ways to provide support, however it is important: 

• To maintain open lines of communication to establish how to best provide both emotional and practical support.
• To keep in mind that every experience is unique to the person who is affected, as is the way they process the fire incident.
• To remember that for those at the frontline, reactions may be delayed as their immediate concern is about the victim. 

1. Challenges

• The challenges of working with high caseloads, high levels of staff turnover, and fragmented services has implications for the invidividuals and the management oversight of cases, in particular how to both manage the emotional impact of the work on staff, and facilitate thoughtful case evaluation and analysis.

2. Service changes

• The impact on staff of service changes and the implications for families they work with was a feature in SCRs, for example in some instances, professionals were not aware when essential support services, particularly from third sector agencies, had ceased to be provided and the implications for child protection practice had not been sufficiently grasped.

3. Supervision

• Safeguarding children work is emotive and has lasting effects for individuals, and managers have a role to promote access to systems of support and eliminate the barriers from taking up support offered;
• Regular supervision or similar opportunities for reflection should be core business for all organisations who have a safeguarding role, and after a significant safeguarding incident consideration should be given to debriefing staff, and how to best provide post-incident support.

4. Debriefs and support systems

• Debriefs following safeguarding children incidents has been considered beneficial following a serious incidents in order to have a clearer understanding of the situation, the reasoning behind the actions and the outcome of the case;
• Reflective group sessions has been found to provide a feeling of mutual support and provided an opportunity to air difficult feelings and emotions;
• The importance of learning stemming from practitioners’ participation in the review was a prominent theme to emerge from the most recent triennial analysis of SCRs.

5. Multi-agency training

• Multi-agency training is recognised to enhance the knowledge and understanding of individual roles and the pressures that each agency may be facing;
• Informed training and on-going learning from past tragedies and experiences is often used as a driving force to improve practises and systems;
• The triennial SCR analysis, included the importance of promoting responsive cultures within child safeguarding systems.