Source · Prevention of Future Deaths

William Thompson

Ref: 2016-0130 Date: 30 Apr 2016 Coroner: ME Hassell Area: London Inner (North) Responses identified: 1 / 1 View PDF

A high-risk service user lacked a smoke detector in his bedroom; social workers failed to assess or address this significant fire safety risk.

Date 30 Apr 2016

56-day deadline 25 Jun 2016 est.

Responses identified 1 of 1

Community health care and emergency services related deaths

Coroner's concerns

AI summary

A high-risk service user lacked a smoke detector in his bedroom; social workers failed to assess or address this significant fire safety risk.

View full coroner's concerns

The evidence I heard at inquest was that, whilst smoke and heat detectors were installed in Mr Thompson’s hall and kitchen, there was no smoke detection system in his bedroom.

He was known to be at significantly raised fire risk because of his smoking, drinking and immobility (he used a Zimmer frame). London Fire Brigade had been called to his home more than once in the past. However, his social workers never addressed their minds to the question of whether there was a smoke detector in his bedroom and, if not, whether that might be useful.

This seems to be an area that would benefit from exploration for particularly high risk service users.

Responses

1 respondent

William Thompson

PDF

Action Taken

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 of the partners and agencies involved with the case. Other measures have also been implemented, some in relation specifically to practice in the Council and others with partners to prevent as far as is possible further deaths in similar situations. (AI summary)

View full response

Dear Coroner Hassell, Re: Prevention of Future Death Report: Mr William Thompson (died 07 . 11. 2014) am writing on behalf of Tim Shields, Chief Executive, in response to the Prevention of Future Deaths Report, dated 30 April 2015, received by us on 11 February 2016. Measures taken by the Council to seek to prevent future deaths in this manner include the & Hackney Safeguarding Adults Board commissioning a Safeguarding Adults Review under the provisions of the Care Act 2014, which has twenty six recommendations for improving practice and procedures across all of the partners and agencies involved with this case_ Other measures have also been implemented , some in relation specifically to practice in the Council and others with partners to prevent as far as is possible further deaths in similar situations to that of Mr Thompson: These are highlighted in the Report and Action Plan attached with this letter as Appendices 1 and 2_ trust that the attached Report and Action Plan provides you with sufficient information to assure you that the measures we have taken are satisfactory and appropriate and sufficiently robust to prevent as far as is possible further death in similar situations_ Should you require further information please do not hesitate to contact me_

Report sections

Investigation and inquest

On 10 November 2014, I commenced an investigation into the death of William Thompson, aged 72 years. The investigation concluded at the end of the inquest earlier today. I made a determination of accidental death.

Circumstances of the death

Mr Thompson died in a fire at his home caused by a discarded cigarette. His bedding caught light and he was killed by smoke inhalation. Mr Thompson lived in supported housing.

Copies sent to

Group Manager, London Fire Brigade

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2016-0130
Date of report: 30 April 2016
Coroner: ME Hassell
Coroner area: London Inner (North)

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 25 Jun 2016 (estimated).

Sent to

London Borough of Hackney

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.