On 16th February 2015 the Senior Coroner commenced an investigation into the death of John Hills born 29 September 1931, being age 84 at the date of his death. An inquest was subsequently opened and adjourned on 17th February 2015 and a Pre-Inquest review held by me on 29 April 2015. The investigation concluded at the end of the inquest on 23 June 2015. The conclusion of the inquest was that Mr Hills died as a result of 40% burns to his face, trunk and limbs, suffering also from COPD and Hypertensive Heart Disease. My conclusion was that Mr Hills had died accidentally.

1. Mr Hills had been resident in a nursing home in Worthing since 2003. He had no family and had been taken into care following incidences of self-neglect at home. He was registered blind and suffered from paranoid schizophrenia. He had mobility issues and at the time of the incident used a wheelchair. He was doubly incontinent (requiring pads) and had a dry skin condition which required a regime of 4-6 x daily full body appliances of Cetraben emollient cream (500 gram).
2. The exact extent of Mr Hills’ capacity was unascertained but it was considered more likely than not that he would have found it difficult to understand complex information about his overall welfare, long term care needs, risk and safety issues.
3. Mr Hills had few interests, but loved to smoke his pipe. It was described as his ‘only pleasure’. For a number of years the home had facilitated this, with a dedicated area for him to smoke. No formal risk assessment or smoking policy was however in place until 22 November 2014 (although this was a property risk assessment rather than a personal one for Mr Hills).
4. On 24 November 2014, Mr Hills had been responsible for a small fire in the conservatory of the care home, where he had been allowed to smoke. It was established that he had flicked a lit match. No personal injury was caused but the small fire required to be extinguished, resulting in property damage.
5. A further risk assessment was subsequently undertaken and measures put in place to reduce the risk of fire in the conservatory (the designated smoking area). This focused on introducing non-combustible materials and furniture as well as fire-fighting equipment. Fire prevention procedures were instigated but no personal risk assessment was undertaken.
6. A fire assessment advisor subsequently attended the home. A new ‘smoking care plan’ was put in place on 8 December 2014. This required Mr Hills (amongst other measures) to wear a fire retardant apron when smoking and to be monitored every 30 mins. The application of Cetraben cream was not noted
7. Mr Hills was a creature of habit and had a number of favourite items of clothing. These included a favourite old cardigan and scarf, both of which he refused to have removed. He would wear both items constantly and sometimes he slept in them. They were rarely washed. He had a habit of wrapping himself in many layers of clothing, with a minimum of 2 blankets wrapped round him. He insisted on wearing his scarf on the outside of his fire apron and it was often a battle to get him to do otherwise. He did not like wearing the fire apron, but would do so if he was told.
8. On 6 February 2015 at approx. 7.40pm, Mr Hills was brought to the conservatory to smoke. He was collected from his room and deposited by a new nurse who had only been with the home for two days. The care home manager took over. He was settled into position by the home manager, and set up with all of his smoking paraphernalia. His pipe was lit for him and his matches were removed. He was left to smoke alone.
9. The evidence established a tragic chain of events. The new nurse believed Mr Hills would be dressed with his apron in the conservatory before smoking and after she had left him – the apron was usually kept on a hook in the conservatory. The manager had assumed that he had it on when he had arrived at the conservatory (it was not on its designated hook and he appeared to be wearing something similar in colour). Sadly, the presence of the apron was not physically checked and consequently Mr Hills was not wearing his fire apron on the evening of 6 February. The apron was subsequently found in a laundry basket, having been washed. The fact not communicated to other staff.
10. At approx. 8pm the fire alarm sounded. Mr Hills was discovered in flames in his chair. The fire was extinguished and emergency services called. He was transferred to hospital but died the following day as a result of his injuries.
11. The fire investigation evidence concluded that Mr Hills had either dropped or placed his lit pipe in his lap. The insulating quality of his incontinence pad had likely precluded his ability to sense the smouldering heat from the tobacco in the pipe which built to a point of ignition where a flame developed. His clothing and blankets were ignited and the flames accelerated by the multiple layers of clothing he wore, including his shirt (which, it was subsequently established, contained a fire hazard warning label).
12. The evidence established that the accelerant quality of the paraffin based emollient cream was, more likely than not, a considerable contributory factor. It was clear that it had been absorbed by his unwashed clothing over a period of time. Although not scientifically proven by the fire officer (his evidence was not based on controlled or laboratory based results), tests undertaken on fabric soaked in ‘wet’ Cetraben and ‘dried’ Cetraben, showed that the soaked and dried product had a much more flammable characteristic than the ‘fresher’ wet soaked fabric and that fire developed 4-5 times faster. None of the staff at the home appeared to be aware of this risk and it was clear that nothing had been mentioned to them or brought to their attention concerning any potential risks at the time the cream was prescribed.