Gabrielle Steel
PFD Report
All Responded
Ref: 2024-0526
All 2 responses received
· Deadline: 29 Nov 2024
Coroner's Concerns (AI summary)
Critical fire safety assessment findings were not communicated by the London Fire Brigade to carers or family, preventing the implementation of a vital risk management plan for a vulnerable individual.
View full coroner's concerns
1. 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. The findings of the home fire safety visit were shared only with Mrs Steel – a vulnerable, elderly lady. The findings were not conveyed to those with responsibility for caring for her.
3. 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 Steel, her family, her carers or the agency who requested the fire safety check.
4. 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 Steel. 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 flammable materials away from the bed, as much as possible.
2. The findings of the home fire safety visit were shared only with Mrs Steel – a vulnerable, elderly lady. The findings were not conveyed to those with responsibility for caring for her.
3. 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 Steel, her family, her carers or the agency who requested the fire safety check.
4. 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 Steel. 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 flammable materials away from the bed, as much as possible.
Responses
Action Planned
The London Fire Brigade is reviewing its processes for sharing home fire safety visit findings with third parties, consulting the Information Commissioner regarding data protection issues, and reviewing questions asked at booking to identify care provision. (AI summary)
The London Fire Brigade is reviewing its processes for sharing home fire safety visit findings with third parties, consulting the Information Commissioner regarding data protection issues, and reviewing questions asked at booking to identify care provision. (AI summary)
View full response
Dear Coroner
Response to Regulation 28 Report to Prevent Future Deaths
I write in response to the Regulation 28 report to prevent future deaths, which you issued following the inquest touching the death of Mrs Gabrielle Steel.
London Fire Brigade (‘LFB’) actions to address concerns following the inquest.
2. The findings of the home fire safety visit were shared only with Mrs Steel – a vulnerable, elderly lady. The findings were not conveyed to those with responsibility for caring for her.
Existing LFB policy, which follows national best practice, does not authorise staff to share findings with any other person. Providing staff are satisfied that the individual recipient is able to understand and retain the advice given, they share advise and observations face to face. During the booking of Mrs Steel’s Home Fire Safety Visit it was confirmed that Mrs Steel was able to understand, process and retain the information provided – this was noted on our records and therefore the crews followed the correct process as outlined in the policy.
Noting HM Coroner’s observations, we have started to review our processes and have engaged with our Information Management Team to discuss the data protection issues around sharing information with third parties where the resident has full mental capacity. LFB are reviewing the data protection privacy impact assessment and consulting the Information Commissioner to fully scope how we can best meet this need while ensuring privacy for the resident.
LFB are reviewing the questions asked at the point of booking the visit to ensure that information is gained regarding whether there is the provision of care in the home and recommend that the carer attends the visit. LFB are also considering the best ways of communicating with the carer or family member if they are not present, for example leaving guidance in the property including information about flame retardant bedding where appropriate.
Following this review LFB will where necessary update the policy, guidance, and training to ensure all staff carrying out Home Fire Safety Visits fully understand this process.
3. A written risk assessment/risk assessment plan was completed by the London Fire Brigade. This was not left in the property or shared with Mrs Steel, her family, her carers, or the agency who requested the fire safety check.
The Fire Service’s statutory role does not include responsibility for a resident’s care plan or for making or contributing to a personalised risk management plan for an individual resident. The purpose of a Home Fire Safety Visit is to provide advice and guidance to help keep the resident safe. At a Home Fire Safety Visit, LFB staff record advice given on a data collection form which is then uploaded into a database. In most cases this information is recorded using a tablet which will populate the database automatically. Existing LFB policy, which follows national best practice, does not authorise staff to share findings with any other person and currently no functionality to be able to leave a copy of the findings with the resident.
The policy currently states that a Home Fire Safety Visit guide with generic advice will be left with the resident, however this would not contain bespoke advice given for example around flame retardant bedding and the importance of always keeping it on the bed.
LFB are scoping options for being able to leave bespoke information with the resident, and with family members or a carer where appropriate. This includes engagement with the National Fire Chiefs Council and other Fire and Rescue Services to identify any areas of best practice. Following this review LFB will where necessary update the policy, guidance, and training to ensure all staff carrying out Home Fire Safety Visits fully understand this process.
4. 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 Steel. 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 safe bedding was in place at all times; the importance of keeping extraneous flammable materials away from the bed; as much as possible.
The Fire Service’s statutory role does not include responsibility for a resident’s care plan or for making or contributing to a personalised risk management plan for an individual resident. Home Fire Safety Visits are not intended to be personal risk assessments but to be provision of fire safety advice to the resident. Care providers are regulated to plan and deliver care based on risk assessments, and this should include assessing risk from fire. A care provider should not need a HFSV to prompt attention on any of the points raised above. However, we accept that there is learning around communication with the carer about identified fire risk within the limitations of UK GDPR/Data Protection A 2018 and for the HFSV process to reinforce the need for care providers to have regard to fire safety. We have set out above that we are taking steps to explore improvements.
LFB has been working to educate carers on a local and pan-London level for several years. There is information for carers on the LFB website and an intranet page with resources for staff to use. LFB have an established relationship with the Care Quality Commission (CQC). The NFCC Person Centred Fire Risk Assessment form is a tool for carers to use to identify and mitigate fire risk for the people they care for. This form is in the process of being updated. The CQC are committed to sharing this information with the care industry.
LFB will engage with Local Authorities to share the learning from this report and reiterate the role of the carer in reducing fire risk. LFB will also share the learning from this report, and our subsequent actions to improve our processes, with other Fire and Rescue Services through the NFCC National Organisational Learning process.
LFB is committed to improving fire safety provisions for vulnerable people who may be in receipt of care across London, with the aim of reducing the number of fires that result in death or serious injury.
Response to Regulation 28 Report to Prevent Future Deaths
I write in response to the Regulation 28 report to prevent future deaths, which you issued following the inquest touching the death of Mrs Gabrielle Steel.
London Fire Brigade (‘LFB’) actions to address concerns following the inquest.
2. The findings of the home fire safety visit were shared only with Mrs Steel – a vulnerable, elderly lady. The findings were not conveyed to those with responsibility for caring for her.
Existing LFB policy, which follows national best practice, does not authorise staff to share findings with any other person. Providing staff are satisfied that the individual recipient is able to understand and retain the advice given, they share advise and observations face to face. During the booking of Mrs Steel’s Home Fire Safety Visit it was confirmed that Mrs Steel was able to understand, process and retain the information provided – this was noted on our records and therefore the crews followed the correct process as outlined in the policy.
Noting HM Coroner’s observations, we have started to review our processes and have engaged with our Information Management Team to discuss the data protection issues around sharing information with third parties where the resident has full mental capacity. LFB are reviewing the data protection privacy impact assessment and consulting the Information Commissioner to fully scope how we can best meet this need while ensuring privacy for the resident.
LFB are reviewing the questions asked at the point of booking the visit to ensure that information is gained regarding whether there is the provision of care in the home and recommend that the carer attends the visit. LFB are also considering the best ways of communicating with the carer or family member if they are not present, for example leaving guidance in the property including information about flame retardant bedding where appropriate.
Following this review LFB will where necessary update the policy, guidance, and training to ensure all staff carrying out Home Fire Safety Visits fully understand this process.
3. A written risk assessment/risk assessment plan was completed by the London Fire Brigade. This was not left in the property or shared with Mrs Steel, her family, her carers, or the agency who requested the fire safety check.
The Fire Service’s statutory role does not include responsibility for a resident’s care plan or for making or contributing to a personalised risk management plan for an individual resident. The purpose of a Home Fire Safety Visit is to provide advice and guidance to help keep the resident safe. At a Home Fire Safety Visit, LFB staff record advice given on a data collection form which is then uploaded into a database. In most cases this information is recorded using a tablet which will populate the database automatically. Existing LFB policy, which follows national best practice, does not authorise staff to share findings with any other person and currently no functionality to be able to leave a copy of the findings with the resident.
The policy currently states that a Home Fire Safety Visit guide with generic advice will be left with the resident, however this would not contain bespoke advice given for example around flame retardant bedding and the importance of always keeping it on the bed.
LFB are scoping options for being able to leave bespoke information with the resident, and with family members or a carer where appropriate. This includes engagement with the National Fire Chiefs Council and other Fire and Rescue Services to identify any areas of best practice. Following this review LFB will where necessary update the policy, guidance, and training to ensure all staff carrying out Home Fire Safety Visits fully understand this process.
4. 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 Steel. 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 safe bedding was in place at all times; the importance of keeping extraneous flammable materials away from the bed; as much as possible.
The Fire Service’s statutory role does not include responsibility for a resident’s care plan or for making or contributing to a personalised risk management plan for an individual resident. Home Fire Safety Visits are not intended to be personal risk assessments but to be provision of fire safety advice to the resident. Care providers are regulated to plan and deliver care based on risk assessments, and this should include assessing risk from fire. A care provider should not need a HFSV to prompt attention on any of the points raised above. However, we accept that there is learning around communication with the carer about identified fire risk within the limitations of UK GDPR/Data Protection A 2018 and for the HFSV process to reinforce the need for care providers to have regard to fire safety. We have set out above that we are taking steps to explore improvements.
LFB has been working to educate carers on a local and pan-London level for several years. There is information for carers on the LFB website and an intranet page with resources for staff to use. LFB have an established relationship with the Care Quality Commission (CQC). The NFCC Person Centred Fire Risk Assessment form is a tool for carers to use to identify and mitigate fire risk for the people they care for. This form is in the process of being updated. The CQC are committed to sharing this information with the care industry.
LFB will engage with Local Authorities to share the learning from this report and reiterate the role of the carer in reducing fire risk. LFB will also share the learning from this report, and our subsequent actions to improve our processes, with other Fire and Rescue Services through the NFCC National Organisational Learning process.
LFB is committed to improving fire safety provisions for vulnerable people who may be in receipt of care across London, with the aim of reducing the number of fires that result in death or serious injury.
Action Planned
The London Borough of Newham will hold a reflective case discussion at the Fire Safety Group, improve training for social care staff on fire safety risk assessment, produce a '7 minute briefing' on fire safety risk management plans, and enhance monitoring where there is an established risk of fire. (AI summary)
The London Borough of Newham will hold a reflective case discussion at the Fire Safety Group, improve training for social care staff on fire safety risk assessment, produce a '7 minute briefing' on fire safety risk management plans, and enhance monitoring where there is an established risk of fire. (AI summary)
View full response
Dear Ms Persaud
Re: Regulation 28 Report concerning Gabrielle Sarah Anne Steel
Response from the London Borough of Newham
Thank you for sharing the conclusion of your Inquest into the death of Gabrielle Sarah Anne Steel, and the subsequent Regulation 28 Report. May I start by expressing my sincere regret and disappointment to learn of the circumstances surrounding Ms Steel’s passing. On behalf of the Council I wish to place on record our deepest condolences to her family, her friends and all those that knew her. We fully acknowledge the findings from the Inquest and are fully committed to putting actions in place to address the concerns raised in the Prevention of Future Deaths report.
A core group of Senior Officers from the department were involved in a detailed review of Ms Steel’s case following her death. The review resulted in an action plan with a focus on prevention, this emphasised a number of interventions including smoking cessation. We have updated our action plan following the Inquest findings; please see below for details of this.
Action: By who: By when: 1 A reflective case discussion at the Fire Safety Group on 10/12/24. The Fire Safety Group is the multi-agency group responsible for fire safety issues in the Borough. This discussion will involve a review of previous reflective sessions Strategic Safeguarding Adviser 10/12/24 2 To further improve training for social care staff by holding a training session on fire safety risk assessment and risk management plans. This session will complement the joint training session which took place on 25/04/24 Workforce Development and Strategic Safeguarding 30/01/25 3 Produce a ‘7 minute briefing on the development of fire safety risk management Workforce Development and 24/12/24
plans. The 7 minute briefing will address the following issues:
1) Escalation procedures regarding fire risks
2) How to obtain feedback from LFB about fire safety risk assessments
3) Reviews of risk assessments and risk management plans
Strategic Safeguarding 4 Enhanced monitoring where there is an established risk of fire for people known to Adult Social Care. The monitoring will take place for the next year with the objective of ensuring learning is embedded Strategic Safeguarding Monitoring to start from 2025
Governance and Oversight
The following people have been sighted on the action plan:
• Corporate Director of Adults (DASS), Commissioning, Health & Social Care
•
-Director of Quality Assurance, Safeguarding and Workforce Development
•
-Head of Service - Older People & Disability, Operations
•
-Head of Service - Older People & Disability, Operations
All elements of the plan are linked to specific teams with accountability for their delivery. Oversight of the action plan is being held by the Strategic Safeguarding Team who will monitor progress against the stated timescales and then report back to the Directorate Management Team. We also recognise that the overall plan will need to remain agile and be adapted if further information comes to light
Thank you again for raising this matter with us. I hope this response gives adequate assurance on the actions we have taken on the improvements required.
Please do not hesitate to come back to me if you require further information or updates.
Re: Regulation 28 Report concerning Gabrielle Sarah Anne Steel
Response from the London Borough of Newham
Thank you for sharing the conclusion of your Inquest into the death of Gabrielle Sarah Anne Steel, and the subsequent Regulation 28 Report. May I start by expressing my sincere regret and disappointment to learn of the circumstances surrounding Ms Steel’s passing. On behalf of the Council I wish to place on record our deepest condolences to her family, her friends and all those that knew her. We fully acknowledge the findings from the Inquest and are fully committed to putting actions in place to address the concerns raised in the Prevention of Future Deaths report.
A core group of Senior Officers from the department were involved in a detailed review of Ms Steel’s case following her death. The review resulted in an action plan with a focus on prevention, this emphasised a number of interventions including smoking cessation. We have updated our action plan following the Inquest findings; please see below for details of this.
Action: By who: By when: 1 A reflective case discussion at the Fire Safety Group on 10/12/24. The Fire Safety Group is the multi-agency group responsible for fire safety issues in the Borough. This discussion will involve a review of previous reflective sessions Strategic Safeguarding Adviser 10/12/24 2 To further improve training for social care staff by holding a training session on fire safety risk assessment and risk management plans. This session will complement the joint training session which took place on 25/04/24 Workforce Development and Strategic Safeguarding 30/01/25 3 Produce a ‘7 minute briefing on the development of fire safety risk management Workforce Development and 24/12/24
plans. The 7 minute briefing will address the following issues:
1) Escalation procedures regarding fire risks
2) How to obtain feedback from LFB about fire safety risk assessments
3) Reviews of risk assessments and risk management plans
Strategic Safeguarding 4 Enhanced monitoring where there is an established risk of fire for people known to Adult Social Care. The monitoring will take place for the next year with the objective of ensuring learning is embedded Strategic Safeguarding Monitoring to start from 2025
Governance and Oversight
The following people have been sighted on the action plan:
• Corporate Director of Adults (DASS), Commissioning, Health & Social Care
•
-Director of Quality Assurance, Safeguarding and Workforce Development
•
-Head of Service - Older People & Disability, Operations
•
-Head of Service - Older People & Disability, Operations
All elements of the plan are linked to specific teams with accountability for their delivery. Oversight of the action plan is being held by the Strategic Safeguarding Team who will monitor progress against the stated timescales and then report back to the Directorate Management Team. We also recognise that the overall plan will need to remain agile and be adapted if further information comes to light
Thank you again for raising this matter with us. I hope this response gives adequate assurance on the actions we have taken on the improvements required.
Please do not hesitate to come back to me if you require further information or updates.
Sent To
- London Borough of Newham
- London Fire Brigade
Response Status
Linked responses
2 of 2
56-Day Deadline
29 Nov 2024
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 6 November 2023 I commenced an investigation into the death of Mrs Gabrielle Sarah Anne Steel (aged 76 years). The investigation concluded at the end of the inquest on the 2 October 2024. The conclusion of the inquest was that Mrs Steel died as a result of an accident.
Circumstances of the Death
Gabrielle Steel suffered a decline in her overall health from January 2023, following the death of her husband. She was admitted to hospital in March 2023 with weakness, malnutrition, and deranged electrolytes. She required admission to hospital for around 3 weeks, following which she was deconditioned, and her mobility was much reduced. On discharge from hospital in April 2023 she was bed bound. Mrs. Steel was known by the multi-agencies supporting her, to be bed bound; to smoke in her bed and to drink alcohol. The risk of fire was recognised, and the local authority occupational therapist requested a fire home safety visit from the London Fire Brigade. A fire home safety visit took place by the London Fire Brigade at her home address on the 3 August 2023. The London Fire Brigade assessor recommended flame retardant bedding. They also recommended to Mrs. Steel that her non-flame-retardant bedding should be disposed of. The flame-retardant bedding was provided promptly, but there was poor communication of the wider fire risk management plan. The outcome of the fire assessment was not shared with Mrs. Steel's daughter, the care agency or the referring occupational therapist. A copy of the fire risk assessment document and management plan was not left within the premises to inform those caring for Mrs. Steel. The local authority care and support plan was updated by a social worker on the 29 September 2023. The fire risk was again recognised, but there is no evidence that any attempt was made to seek the outcome of the fire safety visit or to devise a fire risk management plan. On the late evening of 17 October 2023 the emergency services were called, due to a fire in Mrs. Steel's home address. The fire service attended promptly. A fire was discovered on Mrs. Steel's bed. Mrs. Steel was removed from the address and resuscitation was provided. Sadly, she did not respond to resuscitation and her life was pronounced extinct on scene. A fire investigation determined that the likely cause of the fire was the unsafe disposal of smoking materials on the bed area. The flame-retardant duvet cover was not on the bed at the time of the fire.
Action Should Be Taken
London Borough of Newham – concern (1) London Fire Brigade – concerns (2) to (4)
Copies Sent To
who in my opinion should receive it
You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response
q 3 October 2024 Ms G N Persaud
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.