Gabrielle Steel
3 Oct 2024 · Coroner Nadia Persaud · East London
The coroner's concerns
1. fire risk from smoking in bed
“The risk of fire, due to smoking in bed was recognised by a local authority occupational therapist. A request was made to the London Fire Brigade for a home fire safety visit. The assessment took place promptly, but neither the occupational therapist, nor the social worker enquired into the outcome of the home fire safety visit, so that a risk management plan could be put in place.”
2. lack of communication of fire safety findings
“The findings of the home fire safety visit were shared only with Mrs [name redacted] - a vulnerable, elderly lady. The findings were not conveyed to those with responsibility for caring for her.”
3. risk assessment not disseminated
“A written risk assessment/risk management plan was completed by the London Fire Brigade. This was not left in the property or shared with Mrs [name redacted], her family, her carers or the agency who requested the fire safety 4 check.”
4. absence of fire safety plan for vulnerable elderly
“As a result of the poor communication from the LFB, there was no risk management plan in place to reduce the risk of fire harm to Mrs [name redacted]. Had the findings of the fire assessor been communicated, carers would have been aware of the need to re-iterate the importance of stubbing out cigarettes in an ashtray and not leaving cigarettes to burn out; the need to dispose of all non-flame retardant bedding, to ensure that the safe bedding was in place at all times; the importance of keeping extraneous”