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Learning from severe maladministration – March 2025

Taking the key lessons from our severe maladministration decisions.

About this report 

This report focuses on the ‘Big 6’ building safety compliance areas. 

The 23 complaints involve safety in asbestos, fire, water, gas, electrics and lifts, with issues sometimes interfacing with other disrepair concerns. The cases show the human impact of key obligations not being fulfilled to individuals. 

By grouping these cases together, it is possible to map reoccurring points of service failure and identify areas for learning. 

Learning from severe maladministration report (PDF)

Fire safety 

Following the tragic events at Grenfell Tower, the sector has rightly focused on improving fire safety practices. Whilst we are not responsible for inspecting buildings or enforcing fire safety regulations, there is much to learn from our casework. 

Cases highlighted in the full report relating to fire safety: 

  • Norwich Council 202307882* 
  • Peabody 202307894 and 202204476* 
  • L&Q 202221775*
  • Riverside 202317333* 

Learning from fire safety  

We expect landlords to take issues of fire safety seriously. Any resolution of these issues should include looking at how to minimise the safety risk for residents. 

Landlords should have a process for regular and timely property inspections to identify defects and a mechanism to follow up on repairs, in relation to health and safety, including fire safety. 

Staff should be adequately trained where appropriate to deal with fire safety issues, provide up to date information or progress any works where needed. Whenever issues occur, effective communication is vital due to the extremely sensitive nature of the topic. This should be clear and manage expectations, providing regular updates where possible.  

Landlords should ensure adherence to fire safety legislation and put in place policies that will ensure they are able to meet these in practice. This could include on fire doors, EWS1 forms, fire risk appraisals and PEEPs. 

In its response to the phase 2 Grenfell Tower Inquiry report, the government has also announced that secondary legislation will be introduced later this year for Residential Personal Emergency Evacuation Plans (RPEEPs). 

Where residents have had to chase the landlord for information or action, it should consider the time and trouble as well as the impact on the resident, when handling a complaint. 

Centre for Learning resources

Fire safety fact sheet

Spotlight report on dealing with cladding complaints

Gas safety 

Complying with gas safety regulations is a core component of many maintenance teams’ operations. Whilst thousands of checks will be carried out successfully each week, failings can present considerable risks to residents as well as being a potential breach of regulatory standards. 

Cases highlighted in the full report relating to gas safety: 

  • Southend Council 202234512 
  • Camden Council 202217728* 
  • Clarion 202314634* 
  • Soho Housing 202309829* 

Key learning from gas safety  

Residents should live in a safe environment. With the importance of gas in some resident’s homes for daily activities from heating to eating, it is vital swift and timely action is taken where concerns are reported. 

Landlords are responsible for the gas supply from the gas meter to the appliances it supplies as well as maintenance and repair of the appliances to provide heating and hot water. This reflects the obligations in section 11 of the Landlord and Tenant Act 1985. 

Landlord operatives should understand key legislation around gas safety, including on boilers and flues. This also includes provisions around carbon monoxide, in which the alarm itself should not be used as a substitute for the proper installation and maintenance of gas equipment by a gas safe registered engineer. This follows guidance from the Health and Safety Executive.  

An unresolved carbon monoxide leak has the potential to cause serious harm or even be fatal.  Landlords should treat any report of potential carbon monoxide within a property as an urgent or emergency matter. This would remain the case even where there is an operational carbon monoxide alarm in the property. 

Where complaints about gas safety or leaks are made, landlords must consider the resident’s fuel costs when calculating compensation where relevant. This can be important to ensure the landlord’s communication is empathetic to help rebuild trust with the resident. 

Centre for Learning resources

Decants key topics page

Knowledge and infromation management key topics page

Electrical safety 

Landlords have a statutory duty under section 11 of the Landlord and Tenant Act 1985 to keep the installations for the supply of electricity in good repair. Landlords are responsible for ensuring properties are fit for human habitation, with electrical hazards listed as one of the 29 hazards under the Housing Health and Safety Rating System (HHSRS). This duty means it is required to repair any issues it is responsible for within a reasonable time. 

Cases highlighted in the full report relating to electrical safety: 

  • L&Q 202226880* 
  • Barking and Dagenham Council 202311480 
  • Lambeth Council 202302135* 
  • RHP 202414659* 
  • Birmingham City Council 202313362* 

Key learning from electrical safety   

If a landlord is unable to meet the emergency timescales required around electrical safety, it must consider what alternative arrangements it can offer the resident. This may include an alternative power source or temporarily being moved from the property. 

Considering temporary moves is especially important depending on the time of year and circumstances of the household, especially where children or health conditions are present. 

It is appropriate to make the electrics safe before dealing with the root causes of the issue, but in doing so landlords must maintain clear communication with the resident during what can be a stressful and anxious time, especially if the household contains children.  

Hazards and wider issues with a property’s condition can interlink. A landlord failing to deal with a leak for a long period could cause new problems with electrics and create further damage to the living environment. It is also important for landlords to listen to the resident and their experience of living in the home, to ensure landlords do not miss issues or dismiss valid concerns about electrical safety. 

Centre for Learning resources

Decants key topics page

Knowledge and infromation management key topics page

Asbestos management 

Asbestos legislation, policies and procedures are designed to protect everyone and should be strictly adhered to. Any deviation must be taken seriously and thoroughly investigated. Social landlords can be particularly exposed to asbestos due to the age of housing they own and manage. 

Cases highlighted in the full report relating to asbestos: 

  • Hyde Housing 202302504* 
  • A2Dominion Group 202304843 
  • Lambeth Council 202220339* 

Key learning from asbestos management 

Asbestos is a hazard under the HHSRS, which along with other legislation contributes to a landlord’s overall duty to manage asbestos in its properties. This includes identifying if asbestos is present in a property and making sure the correct survey is carried out. The survey should identify the location of any asbestos in the property, assess how vulnerable it is to damage, and identify any current damage or potential fibre release. 

If asbestos is present, this does not automatically mean that the property is in disrepair. Asbestos can often be safely managed by landlords in situ provided it is covered, in good condition and unlikely to be damaged or disturbed. Landlords must however keep accurate records in relation to all locations of the asbestos and keep its condition under review.  

Landlords are required by various statutory provisions to ensure that tenants, staff and contractors are protected from exposure to asbestos fibres. Where work is required and it is known or suspected that asbestos is present, only individuals with sufficient competency and training should be involved in carrying out the work. 

Landlords should explore what training is needed for its staff and how it can get assurance of an effective response in practice with modern, integrated systems to facilitate it.  

When related to repairs, the presence of asbestos may turn a routine repair into an emergency, requiring nimble triaging where appropriate.  

As with all safety and hazard-related topics, open communication and the provision accurate information to the resident living in the home is essential as the household could be particularly concerned where children or health conditions are present. 

Where resident behaviour is unreasonable, landlords may need to take action to manage the behaviour in accordance with its policies without losing sight of the need to resolve the potential hazard. 

Centre for Learning resources

Decants key topics page

Knowledge and infromation management key topics page

Legionella (water hygiene) 

When considering how to deal with water safety issues, there are many aspects that landlords need to think about, from the cause of the issue itself to how that then manifests itself, from contaminated water to leaks that can cause other significant issues. 

Cases highlighted in the full report relating to water hygiene: 

  • Home Group 202230230* 
  • Lewisham Council 202331984* 
  • L&Q 202230978* and 202306931 
  • Norwich Council 202316688 

Key learning from legionella 

Landlords should make sure there is a safe and clean water supply to a property before occupancy. Where issues occur, including with sanitation, landlords need to make sure they investigate and respond, including considering whether it is an emergency.  

In some cases, the causes can be complex. This means the landlord may need to consider appropriate mitigations, including avoiding financial hardship for the household or a temporary move, especially where the household’s circumstances can present greater risks. 

Communication is also key, with the resident but also between the different parties involved to resolve to issues. 

Centre for Learning resources

Decants key topics page

Knowledge and infromation management key topics page

Lifting Operations and Lifting Equipment Regulations (LOLER) 

Cases highlighted in the full report relating to lifts: 

Learning from LOLER 

Landlords should assess any underlying cause of lift outages to see whether more than a repair is needed and provide clear communication to residents throughout this time. This can be complex and therefore this communication is even more important.

Centre for Learning resources

Decants key topics page

Knowledge and infromation management key topics page

Repairs and property condition fact sheet

Learning from severe maladministration report 

Download the full learning from severe maladministration report to see the case studies in more detail. 

Learning from severe maladministration full report (PDF) 

*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. 

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