Fire risk, vulnerable smokers
Inadequate assessment and mitigation of fire risks posed by vulnerable heavy smokers in care settings.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
77match
Raymond Brattley
The coroner identified that organisations and care settings should consult the Fire Service for advice on mitigating fire risks from vulnerable individuals who smoke, suggesting measures like metal wastepaper bins and fire-retardant materials.
Matched on
terms: fire, vulnerable
PFD report
73match
Vera Lillian Steel
The coroner noted the availability of fire protective aprons for smokers and raised concerns that care homes are not encouraged to provide access to these measures for residents who smoke, following an incident where a resident's clothing caught fire.
Matched on
terms: fire, smoker
PFD report
65match
Maureen Milton
The coroner raises concerns about the lack of awareness among medical professionals, carers, and families regarding the fire risk posed by petrol-based emollient creams, which can impregnate clothing and cause rapid fire spread.
Matched on
terms: fire
PFD report
61match
Santosh Muthiah
The coroner raises concerns about the difficulty in identifying appliance manufacturers and models after severe fires, which hinders the detection of manufacturing defects and assessment of risks. There are also inconsistencies in how fire investigation findings are communicated to manufacturers and Trading Standards nationally.
Matched on
terms: fire
PFD report
61match
Christopher Holyoake
The coroner notes a lack of awareness regarding the flammability of paraffin-based E45 cream among carers and the deceased, attributed to insufficient communication from the GP and an absence of fire hazard warnings on the product packaging and prescription.
Matched on
terms: fire
PFD report
61match
Dorina Zangari
The coroner identified inadequate fire detection and warning systems, a compromised protected means of escape, and outdated alternative escape route designs in the maisonette. These issues are widespread in similar properties, leaving occupants at significant risk from fire.
Matched on
terms: fire
PFD report
61match
Neil Barre
The coroner noted that Staffordshire Fire and Rescue Service might benefit from awareness when domiciliary care recipients do not use provided special fire safety equipment, suggesting improved communication with care providers.
Matched on
terms: fire
PFD report
61match
Darrell Spear
Concerns included delays in addressing significant self-neglect and hoarding issues that posed a fire risk, despite agencies being aware. There was also poor inter-agency communication and no clear strategy to manage these identified risks.
Matched on
terms: fire
PFD report
61match
Pauline Allison
Insufficient awareness among patients, families, and carers regarding the fire risks of flammable emollient creams, especially for immobile persons who smoke. There are gaps in ensuring referral to local Fire & Rescue Services for advice and assistance.
Matched on
terms: fire
PFD report
61match
Brian Harfield
The coroner highlights the lack of compulsory sprinkler or fire safety provisions for individuals in extra care facilities or retirement housing receiving care at home. This group's declining health and mobility increase their fire risk, a gap not addressed by current consultations.
Matched on
terms: fire
PFD report
61match
Jill Brice
The coroner requested reassurance that care residents would be reminded to keep their fire safety pendants close to them at all times, following a recommendation in a fire safety report.
Matched on
terms: fire
PFD report
57match
Julie Ann Camm
The coroner noted the absence of smoke detectors in the property and that fire safety check procedures were not in place. The report recommends the property owner inspect all housing stock to ensure hard-wired or battery-operated smoke detectors are fitted.
Matched on
terms: fire
PFD report
57match
Anthony Lapping
The coroner noted the rapid spread of fire from a Hotpoint fridge freezer's insulation material significantly reduced escape opportunities. Concerns were raised about the risk of further deaths if manufacturers do not review the use of highly flammable insulation in kitchen equipment.
Matched on
terms: fire
PFD report
57match
Robert Spring
There was no direct mechanism for the hospital to notify the fire service of high-risk home oxygen users who smoke, as the oxygen supplier's system prevented full disclosure of the smoking risk. This meant the patient was not assessed for specialist safety equipment, highlighting a need for improved inter-agency communication.
Matched on
terms: fire
PFD report
57match
John Hills
The coroner raises concerns about the lack of fire hazard warnings on paraffin-based emollient creams like Cetraben and insufficient communication of fire risks to patients. Existing guidance may not adequately cover proprietary creams with lower paraffin content.
Matched on
terms: fire
PFD report
57match
Andrew Coates
The coroner noted concerns regarding the suitability of a wooden shed as a firework store, particularly its licence for 1000 kg and the presence of other combustible materials. The licence was also deficient, failing to designate a specific site or type of explosive, and inspection records were incomplete.
Matched on
terms: fire
PFD report
57match
William Thompson
A high-risk service user lacked a smoke detector in their bedroom, and social workers had not considered this despite known fire risks and previous fire brigade call-outs.
Matched on
terms: fire
PFD report
57match
Ellen Kelly
The coroner noted concerns regarding fire safety, specifically that front doors of flats likely lack proper self-closing mechanisms and do not comply with the 30-minute fire-resistant British Standard.
Matched on
terms: fire
PFD report
57match
Terence Penney
Concerns were raised regarding a domestic fridge unit that caused a fire due to a vapour leak when only five years old. The coroner noted the potential for similar leaks in other units of the same type, particularly older ones, as many are still in circulation.
Matched on
terms: fire
PFD report
57match
Christopher Hart
The coroner noted that Johnnie Johnson Housing imposes no conditions on tenants regarding furniture fire safety standards and is not undertaking a formal review into introducing sprinkler systems into its properties.
Matched on
terms: fire
PFD report
57match
Riley Holt, Keegan Unitt, Tilly-Rose Unitt and Olly Unitt
The coroner noted that children under 16, particularly boys, may not respond to conventional smoke alarms. This indicates a need for fire suppression systems to be legally required in all new-build properties in England.
Matched on
terms: fire
PFD report
57match
Sylvia Griffiths
The coroner identified a need for improved communication regarding fire/smoke alarms designed for people with dementia and greater collaboration with support groups to promote their use.
Matched on
terms: fire
PFD report
57match
Henry Boddy
The coroner noted a gap in enforcement powers to address fire risks in residential properties, particularly those arising from hoarding behaviour.
Matched on
terms: fire
PFD report
57match
Mizanur Rahman
The coroner highlighted the absence of British or European standards for lithium-ion e-bike batteries and chargers, which facilitates the sale of unsafe products and increases the risk of thermal runaway, fires, and deaths.
Matched on
terms: fire
PFD report
57match
Bobby Lee
The coroner noted a significant rise in fires from e-bikes/e-scooters, particularly due to inferior quality lithium-ion batteries and unsuitable chargers in conversion kits. Concerns were raised about the lack of specific safety standards for these products, leading to risks like mixing batteries with incorrect voltage chargers.
Matched on
terms: fire
PFD report
57match
Muhammad & Naemat Esmael
The coroner raised concerns that current Welsh legislation for rented properties, requiring only two smoke alarms, may not adequately protect against fires in individual rooms, posing a continuing risk to life. Additionally, items were removed from the fire scene before a full expert inspection, which hindered the investigation into the fire's cause.
Matched on
terms: fire
PFD report
53match
Cedric Skyers
BUPA's smoking risk assessment process and documentation did not sufficiently recognise or mitigate risks for immobile residents who smoke outside and cannot summon help. There were also gaps in recording offered risk mitigation measures and choices against professional advice.
Matched on
classifier match
Detention investigation recommendation
52match
Assessment of government progress in implementing the report on the welfare in detention of vulnerable persons - Rec...
As set out in the NHSE, Home Offce and PH(E) National Partnership Agreement, all centres should become smoke-free as soon as possible, subject to proper planning and support for detainees and staff.
Matched on
terms: vulnerable
PFD report
49match
Sheila Gaskin
Despite an identified risk of the deceased smoking in bed, the care plan did not prohibit carers from assisting with this, which occurred regularly. Management also lacked effective day-to-day oversight of this activity.
Matched on
classifier match
PFD report
49match
Daphne Holloway and Ivy Spriggs
Sprinkler systems are not a mandatory requirement for care homes with immobile occupants, and such homes are not deemed 'Higher Risk Buildings' unless they meet specific height or storey criteria, despite occupant vulnerability.
Matched on
classifier match
CQC action
48match
Barton Park Nursing Home
One of the fire door closures did not work correctly and there were further doors which were propped open around the home.
Matched on
terms: fire
Committee recommendation
47match
#11 - Nineteenth Report - Protecting consumers from unsafe products
The London Fire Brigade told us that low-income households may face higher product safety risks, as they are more likely to purchase cheaper or counterfeit products.20 The OPSS said it aims to ensure that all products sold in the UK are safe, regardless of what price they are sold at and who they are being used by. It...
Matched on
terms: fire, vulnerable
PFD report
45match
Amanda Richards
The coroner asked the housing provider to consider installing domestic sprinkler systems in special accommodation, noting that their provision would have made the death far less likely.
Matched on
classifier match
PFD report
45match
Irene Hamilton-Parker
The coroner noted the high flammability of man-made fabric clothing worn by the deceased and enquired about potential measures to reduce the flammability of manufactured or imported garments in the UK.
Matched on
classifier match
PFD report
45match
Sadie Peters, Joseph Peters and George Peters
The coroner raises concerns about insufficient awareness among caravan users and residents regarding the importance of fitting and maintaining smoke detectors in mobile and static caravans.
Matched on
classifier match
PFD report
45match
Steven Billington
The coroner identified that the on/off control-switch for the mains powered alarm system was unprotected and could be switched off. It was noted that this control could easily be secured, despite current regulations not requiring it to be inaccessible.
Matched on
classifier match
PFD report
45match
Roy Lawton
The coroner noted the high inflammability of a dressing gown worn by Mr Lawton, regardless of its fabric composition. Concerns were raised about potential measures in production, import, or retail to reduce inflammability or warn customers of the danger.
Matched on
classifier match
PFD report
45match
Kevin Branton, Richard Smith, Audrey Cook, Alfred Cook and Maureen Cook
The coroner identified the absence of a national database for gas appliances, noting that a lack of mandatory recording hinders communication between parties and makes tracing potentially dangerous items difficult and time-consuming.
Matched on
classifier match
PFD report
45match
Bernadette Faulkner
The coroner raised concerns about the unsafe height and placement of electricity meters, particularly prepayment meters which require frequent access. The report notes a lack of industry standards for meter accessibility and insufficient records from the installing company regarding placement considerations.
Matched on
classifier match
Inquiry recommendation
39match
P2-8 - Require fire engineer calculations for fire spread and evacuation
Calculating the likely rate of fire spread and the time required for evacuation, including the evacuation of those with physical or mental impairments, are matters for a qualified fire engineer. We do not think that it would be helpful to attempt to include in Approved Document B an indication of what would be acceptable because each building is...
Matched on
terms: fire
LGO / SPSO decision
18match
PSOW-202103888 - Cardiff Council
Ms A complained that Cardiff Council (“the Council”) had failed to maintain the flat she resided in. She stated that some work had been carried out over the past year but that there were still issues that required further attention. Ms A was unhappy with the written response she had received from the Council. The outstanding issues were...
Matched on
classifier match
LGO / SPSO decision
18match
PSOW-202103115 - Hafod Housing Association
Ms A, who was a tenant of Hafod Housing Association (“the Association”) complained about a delay in undertaking repairs at her home which she said was affecting her health and wellbeing. Consequently, she had also applied for a transfer although would preferably want to stay at the property. Ms A also noted a medical need for requiring a...
Matched on
classifier match
LGO / SPSO decision
18match
21-004-788 - Southampton City Council
Summary: Mr X complained on behalf of Ms B and Mr C that the Council failed to take action to ensure their landlord completed remedial works to their private rented property within a reasonable time. We found the Council took appropriate action to ensure the landlord completed the required works within a reasonable time given the difficulties caused...
Matched on
classifier match
LGO / SPSO decision
14match
PSOW-202104624 - Linc Cymru Housing Association
Ms A complained about outstanding maintenance issues at her home address. She said that contractors had visited the property and informed her that some the issues are also affecting other residents on the development. The Ombudsman found that Ms A had submitted a previous complaint to his office which was closed on the basis that the Housing Association...
Matched on
classifier match
LGO / SPSO decision
14match
PSOW-202103137 - Valleys To Coast Housing
Ms A complained, on behalf of her mother, Mrs B, that Valleys to Coast Housing (“the Housing Association”) failed to take appropriate action to deal with a leaking roof at Mrs B’s home. Ms A was unhappy with the remedial patching works undertaken and said that the roof needed to be replaced in its entirety. Ms A was...
Matched on
classifier match
LGO / SPSO decision
14match
PSOW-202207159 - Trivallis
Miss X complained that Trivallis had cancelled and rescheduled operative appointments and she still had outstanding repairs to her shower. The Ombudsman decided that there had been delays and oversights with the appointments and that Trivallis had closed its file before the repairs had taken place. She said this caused frustration and uncertainty to Miss X. She decided...
Matched on
classifier match
LGO / SPSO decision
14match
PSOW-202207603 - Cardiff Council
Mr L complained that the Council had failed to resolve the issue of damp and mould in his property and keep him updated with any progress. The Ombudsman decided that there had been a delay by the Council to rectify the issue and this had caused inconvenience and frustration for Mr L. As an alternative to an investigation,...
Matched on
classifier match
LGO / SPSO decision
14match
PSOW-202303510 - Carmarthenshire County Council
Mrs G complained that Carmarthenshire County Council failed to undertake the necessary repairs to her flat. The Ombudsman found that whilst the Council had issued a Stage 1 complaint response it had failed to escalate Mrs G’s concerns to Stage 2 of its complaints process. She said that this caused frustration and uncertainty to Mrs G. She decided...
Matched on
classifier match
LGO / SPSO decision
14match
PSOW-202303088 - Trivallis
Mr E complained that Trivallis failed to action a roof repair which has been ongoing for over 6 months. The Ombudsman found that there had been a delay in Trivallis undertaking the repairs required. Furthermore, Trivallis had failed to provide regular and meaningful updates to Mr E. She said that this caused frustration and uncertainty to Mr E....
Matched on
classifier match
LGO / SPSO decision
14match
PSOW-202302422 - United Welsh Housing Association
Ms A complained that United Welsh Housing Association (“the Housing Association”) had not responded to a complaint she had made to it about damp at her property. She complained that the damp in her home had been worsening and her attempts to get the Housing Association to rectify the issues had been ignored. The Ombudsman found that whilst...
Matched on
classifier match