Fire risk, vulnerable smokers
Inadequate assessment and mitigation of fire risks posed by vulnerable heavy smokers in care settings.
Source spread
Where this theme appears
This theme appears across 6 independent accountability sources, so the source mix matters as much as the headline total.
1 inquiry rec
36 PFD reports
1 committee rec
2 CQC actions
1 detention investigation rec
15 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Prevention of Future Deaths reports(36)
Vera Lillian Steel
Concerns: 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.
Overdue
Julie Ann Camm
Concerns: 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.
Response (Leeds City Council): • The Electrical Specification was updated to require hard-wired smoke detection during any major electrical works, replacing the previous policy. • Annual tenancy visits, effective 1st April 2014, will include … (AI summary)
Responded
Anthony Lapping
Concerns: 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.
Response (Indesit): • The company confirmed that safety standards and component specifications have evolved since 1998, including the introduction of the Glow Wire Test in 2002. • The company stated that from … (AI summary)
Responded
Amanda Richards
Concerns: 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.
Response (Whitefriars Housing): • Whitefriars Housing Group confirmed it had attended a serious incident review led by the West Midlands Fire Service. • Whitefriars Housing Group committed to working with other agencies to … (AI summary)
Responded
Santosh Muthiah
Concerns: 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.
Response (AMDEA): • AMDEA ensures Fire & Rescue Services are supplied with contact details for its members. • AMDEA's Technical Manager prepared a proposal for changes to international standard IEC 60335-2-24, which … (AI summary)
Response (BSI): • The UK submitted proposals to the International Electrotechnical Commission (IEC) SC 61C for a flame retardant covering over foam insulation and improved testing for the fire resistance of outer … (AI summary)
Response (Forensic Sciences): • The Chartered Society of Forensic Sciences stated that it is not placed or required to report information regarding specific appliances or apparatus that may have caused a fire. • … (AI summary)
Response (Chief Fire Officers Association): • CFOA has been engaged in work since early 2014 to improve information sharing between Fire and Rescue Services (FRS) and Trading Standards (TS). • CFOA will continue to engage … (AI summary)
Response (Department for Business Innovation Skills): • The Department for Business, Innovation and Skills (BIS) will continue to support industry efforts to develop a proposal for white goods to carry key information on a fire-resistant plate. (AI summary)
Responded
Robert Spring
Concerns: 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.
Response (United Lincolnshire Hospitals NHS Trust): • United Lincolnshire Hospitals NHS Trust (ULHT) met with Lincolnshire Fire & Rescue (LF&R) and Air Liquide to agree a new information-sharing process, which has been incorporated into Trust policy. … (AI summary)
Responded
Irene Hamilton-Parker
Concerns: 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.
Responded
John Hills
Concerns: 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.
Response (CFOA): • CFOA disseminated information from the case to all fire and rescue services through internal communications channels. • CFOA will use its safety campaign weeks and other channels to promote … (AI summary)
Overdue
Andrew Coates
Concerns: 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.
Response (Cumbria County Council): • Cumbria County Council provided training to all operational Trading Standards Officers and fireworks administrators on The Explosives Regulations 2014, specifically covering storage and licensing requirements. • The Council reviewed … (AI summary)
Responded
Christopher Holyoake
Concerns: 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.
Response (Reckitt Benckiser Group Plc): • Reckitt Benckiser Group Plc conducted an additional safety assessment of its E45 product portfolio regarding potential flammability risk. • The company will submit an application to the Medicines and … (AI summary)
Response (Chief Fire Officers Association and MHRA): • The Chief Fire Officers Association circulated the Regulation 28 report to fire and rescue services and will ensure its information is shared with appropriate staff. • The MHRA issued … (AI summary)
Response (NHS England): • NHS Improvement worked with the Medicines and Healthcare products Regulatory Agency (MHRA) to reduce the risk of future deaths. • NHS Improvement informed the British National Formulary (BNF) editors … (AI summary)
Responded
William Thompson
Concerns: 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.
Response (William Thompson): • The Hackney Safeguarding Adults Board commissioned a Safeguarding Adults Review under the Care Act 2014. • Other measures have been implemented by the Council and its partners, as detailed … (AI summary)
Responded
Sadie Peters, Joseph Peters and George Peters
Concerns: 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.
Response (Peters): • The Caravan Club provides advice and guidance to its members on fire safety, including a recommendation to fit smoke detectors. • The Club periodically reminds members about the need … (AI summary)
Response (Surrey Fire and Rescue Service): • Surrey Fire and Rescue Service (SFRS) conducted community fire safety visits at identified mobile and static caravan sites, fitting smoke and carbon monoxide alarms. • SFRS continues to employ … (AI summary)
Overdue
Steven Billington
Concerns: 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.
Response (Department for Communities and Local Government): • Officials examined the relevant standards for the installation of fire detection and alarm systems. • The department noted that current guidance in British Standard 5839 requires isolators for fire … (AI summary)
Responded
Ellen Kelly
Concerns: 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.
Response (London Borough of Camden): • The London Borough of Camden completed a £5m programme of fire safety works to 4,500 high priority housing properties, which included renewing or upgrading flat entrance doors to FD30s … (AI summary)
Responded
Roy Lawton
Concerns: 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.
Response (MS): • M&S commissioned external experts to conduct flammability testing on a similar dressing gown. • The testing indicated the product passed flammability standards, with a lit cigarette burning out without … (AI summary)
Responded
Sheila Gaskin
Concerns: 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.
Response (CSSIW): • CSSIW committed to issuing general guidance to care providers on assessing and mitigating smoking-related risks. • The guidance would advise that care workers would not ordinarily assist people to … (AI summary)
Response (CQC): • CQC clarified that the care provider for Ms Gaskin was not regulated by CQC. • CQC described its existing inspection methodology for regulated services, which includes assessing risk management … (AI summary)
Responded
Dorina Zangari
Concerns: 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.
Overdue
Terence Penney
Concerns: 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.
Overdue
Christopher Hart
Concerns: 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.
Response (Johnnie Johnson Housing): • The housing provider updated its advisory information on fire safety regulations. (AI summary)
Responded
Maureen Milton
Concerns: 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.
Response (Department of Health and Social Care): • The Medicines and Healthcare products Regulatory Authority (MHRA) communicated information about the risk of severe and fatal burns with emollient creams in December 2018. • The MHRA convened a … (AI summary)
Response (National Institute for Health and Care Excellence): • NICE stated it does not consider any action is required from its organisation regarding awareness of petrol-based emollient fire risks. • NICE noted that its remit does not include … (AI summary)
Response (UK Health Security Agency): • Public Health England stated it had no comments to add regarding the report. • It indicated that the Medical and Healthcare products Regulatory Agency (MHRA) would be better placed … (AI summary)
Responded
Riley Holt, Keegan Unitt, Tilly-Rose Unitt and Olly Unitt
Concerns: 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.
Response (Ministry of Housing, Communities and Local Government): • The relevant technical committee at the British Standards Institute considered the specific issue of smoke alarms waking children. • An amendment to BS 5839-6 was issued this year, taking … (AI summary)
Responded
Neil Barre
Concerns: 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.
Response (Staffordshire Fire and Rescue Service): • Staffordshire Fire and Rescue Service will conduct a fatal fire review to identify multi-agency learning and inform future prevention and partnership activity. • The service operates an 'Olive Branch' … (AI summary)
Responded
Sylvia Griffiths
Concerns: 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.
Response (Staffordshire Fire and Rescue Service): • Staffordshire Fire and Rescue Service will conduct a fatal fire review to capture multi-agency learning and inform prevention activity. • The findings from the inquest, particularly regarding fire and … (AI summary)
Responded
Kevin Branton, Richard Smith, Audrey Cook, Alfred Cook and Maureen Cook
Concerns: 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.
Response (MP BEIS): • The Office for Product Safety and Standards (OPSS) has established a national Product Safety Database. • OPSS has commissioned research to encourage greater registration of products to facilitate corrective … (AI summary)
Overdue
Darrell Spear
Concerns: 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.
Overdue
Henry Boddy
Concerns: The coroner noted a gap in enforcement powers to address fire risks in residential properties, particularly those arising from hoarding behaviour.
Response (Home Office): • The Home Office stated that the Regulatory Reform (Fire Safety) Order 2005 applies to communal areas of residential buildings, and Fire and Rescue Authorities (FRAs) can issue prohibition notices … (AI summary)
Overdue
Pauline Allison
Concerns: 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.
Response (CCGs): • The CCGs stated they would re-issue a warning in their September newsletter to primary care, encouraging referrals to the Fire and Rescue Service for at-risk patients. • They committed … (AI summary)
Response (British Medical Association): • The British Medical Association stated it does not believe it is the appropriate organisation to achieve the outcome of raising awareness about emollient cream risks. • The British Medical … (AI summary)
Responded
Daphne Holloway and Ivy Spriggs
Concerns: 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.
Overdue
Cedric Skyers
Concerns: 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.
Response (Lewisham Safeguarding Adults Board): • Lewisham Safeguarding Adults Board commissioned a Safeguarding Adult Review (SAR) in April 2016. • The SAR's terms of reference were reviewed and revised, and an independent overview author was … (AI summary)
Response (BUPA): • Bupa completed a review of its smoking risk assessment documentation and process. • The revised Safe Smoking Assessment document requires staff to offer smoking aprons, issue pendant alarms to … (AI summary)
Response (CQC): • The Care Quality Commission (CQC) is assisting the Fire Authority with a joint investigation to consider potential criminal enforcement action against the registered provider. • The CQC reported that … (AI summary)
Responded
Brian Harfield
Concerns: 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.
Response (Department for Levelling Up Housing and Communities): • The Department for Levelling Up, Housing and Communities has a dedicated research workstream in place to gather evidence on sprinklers and other fire protection measures in specialised housing. • … (AI summary)
Responded
Mizanur Rahman
Concerns: 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.
Response (Product Safety and Standards): • The Office for Product Safety and Standards (OPSS) published an updated standard for Electrically Power Assisted Bicycles for designation and plans to remove a restriction on battery packs. • … (AI summary)
Responded
Jill Brice
Concerns: 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.
Response (CQC): • The CQC undertook a rapid review of the concerns raised in the report. • The CQC established that the location was not registered with them and provisionally outside their … (AI summary)
Response (CQC): • The CQC stated it was unable to provide reassurance or comment on the concern. • The CQC indicated that the Teachers Housing Association is not regulated by the CQC. … (AI summary)
Responded
Bobby Lee
Concerns: 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.
Response (Product Safety and Standards): • A government taskforce has been established to determine the root causes of fires from e-bike and e-scooter batteries. • The Office for Product Safety and Standards (OPSS) has published … (AI summary)
Responded
Bernadette Faulkner
Concerns: 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.
Response (Energy Industry): • Energy UK stated it would work with consumer groups to promote existing guidance on meter safety and encourage customers to contact suppliers with concerns. • Energy UK committed to … (AI summary)
Response (Department of Health and Social Care): • Ofgem introduced new rules in November 2023 restricting involuntary prepayment meter installations for certain vulnerable groups. • These new rules require suppliers to make contact attempts and conduct site … (AI summary)
Responded
Raymond Brattley
Concerns: 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.
Response (Royal Society for the Prevention of Accidents): • RoSPA stated it would review and update its advice and education materials regarding fire prevention in sheltered premises. • RoSPA indicated it would explore collaboration with professionals in the … (AI summary)
Responded
Muhammad & Naemat Esmael
Concerns: 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.
Response (Mid and West Wales Fire and Rescue Service): • The Service has previously raised concerns with the Welsh Government regarding smoke alarm coverage in domestic dwellings. • The Service will support proposals for legislative enhancement by the Welsh … (AI summary)
Response (Welsh Government): • The Welsh Government stated that the findings of the Regulation 28 report will be considered alongside an ongoing independent evaluation of the Renting Homes (Wales) Act 2016. • This … (AI summary)
Responded
Select committee recommendations(1)
CQC inspection actions(2)
LGO / SPSO decisions(15)
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 …
PSOW (Public Services Om…
Local Government
Oct 2021
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 …
PSOW (Public Services Om…
Housing
Oct 2021
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 …
PSOW (Public Services Om…
Housing
Oct 2021
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 …
PSOW (Public Services Om…
Housing
Oct 2021
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 …
PSOW (Public Services Om…
Mar 2023
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 …
PSOW (Public Services Om…
Local Government
Mar 2023
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 …
PSOW (Public Services Om…
Local Government
Aug 2023
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 …
PSOW (Public Services Om…
Aug 2023
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 …
PSOW (Public Services Om…
Housing
Sep 2023
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 …
LGO (Local Government & …
Housing
Upheld
May 2022
PSOW-202100263 — Bron Afon Community Housing Ltd
Mr X complained that the Housing Association had not replaced a carpet which had been damaged by a water leak at his property. Instead it had agreed to a give a financial payment which Mr X said was not sufficient to enable him to replace the carpet. The Ombudsman’s office …
PSOW (Public Services Om…
Housing
May 2021
PSOW-202006336 — Trivallis
Mr X complained that the Association had failed to start or complete any of the work to his property, as outlined in their complaint response to him dated 18 December 2020. In considering the complaint, the Ombudsman was concerned about the delays that Mr X had experienced, that the Association …
PSOW (Public Services Om…
May 2021
PSOW-202005311 — Valleys To Coast Housing
Mr X complained that Valleys To Coast Housing (“the Association”) had failed to complete the schedule of work required as part of an improvement notice that was issued by his local authority’s Environmental Health department, intended to resolve problems associated with damp at his house. The Association agreed to write …
PSOW (Public Services Om…
Housing
May 2021
22-011-599 — Stevenage Borough Council
Summary: We will not investigate Miss X’s complaint about the Council’s maintenance of trees near her property. There is not enough evidence of fault by the Council in its decision-making process to justify us investigating. The complaint is also late and there is no good reason for us to investigate …
LGO (Local Government & …
Environment And Regulation
Dec 2022
24-019-571 — Walsall Metropolitan Borough Council
Summary: We cannot investigate this complaint about disrepair in
LGO (Local Government & …
Housing
Apr 2025