Learning from severe maladministration report – December 2024
Taking the key lessons from our severe maladministration decisions.
About this report
Our latest learning from severe maladministration report, focuses on 12 of the 29 hazards ahead of the introduction of Awaab’s Law.
The report is set out by hazard category, sometimes multiple, and show the significant harm that can be caused when hazards are not identified and then dealt with effectively. Hazards covered include contaminated water supply, risk of falls, unsafe electrics as well as damp and mould.
This page provides a summary of the report, to read the case studies in full and hear from the Ombudsman, please download the full report PDF.
Improvement notices, falls and fire
Property condition is the top complaint category at the Ombudsman and many cases could contain a hazard. In many of these cases, landlords have failed to identify the need for more urgent action where a hazard is present and in this first case study this includes taking appropriate action following the intervention of environmental health.
Cases highlighted in the full report:
- Platform Housing Group 202208458
- Clarion Housing Association Limited 202231277
- L&Q 202225494*
- Peabody 202317044*
Key learning related improvement notices, falls and fire
When there is disrepair that leads to a hazard, landlords must undertake a form of health and safety or risk assessment, investigating the hazard and understanding the impact it is having or could have on the household.
Where a contractor is involved in repairing the hazard, the landlord is still responsible for the level and standard of the service it expects to see.
Landlords also must make sure that effective communication occurs during the lifetime of a case, especially where a situation may have an adverse impact on them.
It is best practice for landlords to appropriately record information including any reports of repairs, agreed actions, or further issues raised by a resident. The failure to create and record information accurately can result in landlords not taking appropriate and timely action, missing opportunities to identify that actions were wrong or inadequate, and contributing to inadequate communication and redress.
Centre for Learning resources
Knowledge and information management key topics page
Damp and mould and overcrowding
The impact that damp and mould can have on the health of residents has been well documented by medical professionals, in Ombudsman reports, and in the media.
While this report could have highlighted another 100 cases as the Ombudsman did a couple of months ago, these examples relate to specific hazardous conditions that will help landlords prepare for the introduction of Awaab’s Law.
Cases highlighted in the full report:
Key learning related to damp and mould and overcrowding
Tackling damp and mould with a zero-tolerance approach should be how all landlords approach the issue. It can be caused by various factors, such as leaks, which can be complex to deal with and resolve. However, landlords should make sure that where this is the case it is communicating clearly with the resident to understand the impact the damp and mould is having on the household.
There is an expectation when a hazard such as this is present that risk assessments are done to seek out whether a temporary move is needed. It may also be that works are prioritised or alternatives sought, such as replacement windows, doors or other drivers, to achieve speedier resolution.
Landlords should also be mindful of the impact on residents in this situation when considering redress, and the compensation offered should reflect the severity and length of time in recognition of the impact and distress caused. This must include personal circumstances, which changes the level of impact.
Centre for Learning resources
Hygiene and water supply
While there may be occasions that the water supply is the responsibility of the water company, there are also various aspects that the landlord has obligations for.
Case highlighted in the full report:
- Clarion 202123938
Key learning related to hygiene and water supply
Landlords should make sure they are aware of their role and responsibilities surrounding this key hazard and the impact it can have on any household it affects. Any hazards, including those that may be more uncommon than others, should be treated with the same urgency and landlords investigate swiftly and communicate effectively.
Working with third parties is also key and this should be done efficiently and in a timely manner to make sure that resolution for a resident is not delayed.
Centre for Learning resources
Knowledge and information management key topics page
Excess cold or heat
Guidance for the HHSRS sets out that a healthy indoor temperature is approximately 21°C and that temperatures below 16°C or above 25°C, may pose serious health risks, particularly for elderly or more vulnerable residents.
Cases highlighted in the full report:
- Anchor Hanover 202210054
- Metropolitan Thames Valley 202218270*
Key learning related to excess cold or heat
The HHSRS offers landlords a risk-based tool to enable them to consider potential hazards. This is useful as landlords have a responsibility to keep properties free from category 1 hazards, which includes excess cold or heat.
The adverse health effects of high indoor temperatures are recorded as dehydration, trauma, increased risk of stroke, cardiovascular and respiratory difficulties. It is the landlord’s responsibility to make sure that these increased risks are managed and monitored.
These are important health aspects that landlords should be aware of when dealing with issues of this kind, especially when it is in the peak of summer or winter. Where there are reports of this from residents in a block, it should investigate the impact this is having on other residents in a similar position.
Early monitoring of these issues is vital to build up a picture of what is occurring and how the landlord can best resolve the situation. This can help landlords make effective safeguarding referrals where appropriate, and work with other agencies to provide the best possible support to residents.
It may be necessary for landlords to approach the courts to gain access, and landlords should consider this where appropriate. Given the time this can take and further deterioration of the relationship with the resident, landlords should also explore all opportunities to rebuild the relationship to resolve issues, including mediation.
Centre for Learning resources
Pests
This is an area where responsibilities between the resident and landlord can become confused, and landlords may miss opportunities to take action.
In all cases of pest infestations, it is key for landlords to understand that this may take multiple visits and that communication with a resident is paramount to make sure that confidence in the actions can be maintained.
Cases highlighted in the full report:
- Curo Group 202213016*
- Onward Homes 202223799*
Key learning related to pests
Landlords should inspect all reports of infestation in a timely manner and try and get to grips with the entry points as soon as possible.
It is important that landlords maintain effective communication with the resident throughout this process, to show the progress being made and what alternative action may be needed. Depending on the severity and individual circumstances within the home, landlords should assess whether a temporary move is needed and what is most appropriate.
As it seeks to eradicate the issue from the home, the landlord should make sure there are follow up appointments to access the entry points and whether the action taken has been successful.
Centre for Learning resources
Asbestos
The presence of asbestos in properties, particularly older properties, is common and in itself does not constitute disrepair, nor is it usually hazardous to residents.
However, landlords have several legal obligations when asbestos is damaged or deteriorates as it can release asbestos dust into the air which has been linked to an increased prevalence of several long-term health conditions.
Case highlighted in the full report:
- North Northamptonshire Council 202220918*
Key learning related to asbestos
Exposed asbestos is a known health risk, particularly when exposure is over a protracted period, this delay may have placed the resident at risk for this period. Taking timely action on the removal of this gives residents and landlords the assurance that it is being taken seriously and the hazard removed.
Where appropriate, a temporary move may be considered by landlords, but this would first require an assessment and inspection of the asbestos present in the home.
Electrical
While other categories in this report have shown the impact that electric hazards can create as a byproduct of damp and mould or leaks, it is important that landlords understand how to minimise the exposure to this hazard.
Cases highlighted in the full report:
- Clarion 202318476*
- Longhurst Group 202208215*
Key learning related to electrical
When properties become void – or vacant – this is an opportunity for landlords to undertake works and remove hazards in line with their voids policy.
It is vital that landlords are confident that the necessary works are being completed, including electrical safety, and that its records support this. It is also important that when a resident is complaining about electrical issues, that landlords use that individual complaint to be confident that other properties or a block are not being impacted too.
Centre for Learning resources
Knowledge and information management key topics page
Carbon monoxide
Housing Health and Safety Rating System (HHSRS) details that inadequate ventilation in relation to carbon monoxide can have an impact on the health of residents. This includes the inability of blood to take up oxygen, which can cause headaches, dizziness, nausea, unconsciousness, and death.
Case highlighted in the full report:
- Southern Housing 202317874
Key learning related to carbon monoxide
There are various proactive measures that landlords can take when dealing with a carbon monoxide complaint such as making sure there is adequate air supply for gas appliances, adequate ventilation in rooms with gas appliances, and properly situated carbon monoxide detectors.
These measures can keep residents safe from harm but also enable them to feel reassured that if a problem does occur, there are mitigations in place.
A leak such as this can be distressing, especially if there are children or vulnerabilities in the household. Strong and proactive communication is vital for landlords.
Where one resident is impacted, landlords should consider whether enquiries are necessary with other residents to make sure that a hazard is being addressed.
Centre for Learning resources
Knowledge and information management key topics page
*All decisions are anonymised so residents’ names are not used, but landlords are named. In some cases, we may decide not to publish a decision if it is not in the resident’s or landlord’s interest or the resident’s anonymity may be compromised.