Raymond Brattley
PFD Report
All Responded
Ref: 2024-0424
All 1 response received
· Deadline: 27 Sep 2024
Coroner's Concerns (AI summary)
There are inadequate fire prevention measures for vulnerable, heavy-smoking residents in care settings. Organisations should consult the Fire Service for advice on mitigating risks, such as using metal bins and fire-retardant materials.
View full coroner's concerns
It was known to the staff at Portland Mews that this gentleman was a heavy smoker and that on a number of previous occasions, he set fire to waste paper bins in his flat as well as burning himself, carpets and soft furnishings due to careless smoking. On all previous occasions, the fires were contained or extinguished. Appropriate action was taken by the staff in respect of this issue. However, in the most general of terms, evidence was heard from a fire investigator, that if issues of this nature arise in other organisations or care settings, they should be brought to the attention of the Fire Service, who would freely provide advice about ways in which to mitigate the ongoing and foreseeable risk of cigarette related fires occurring in other vulnerable individuals. Such measures might include the provision of metal wastepaper bins and the use of fire-retardant materials. It is recognised that in similar institutions, tenants are permitted to smoke on such premises, but there is a tension between allowing smoking on the premises and risk of fires occurring, particularly in vulnerable individuals who may have similar mobility problems to Mr Brattley.
Responses
Action Planned
RoSPA will review and update fire safety information for sheltered premises on their website in Q4 2024, explore collaborations with professionals in the sector in Q1 2025, and develop a policy position on fire safety in sheltered accommodation in Q1 2025. (AI summary)
RoSPA will review and update fire safety information for sheltered premises on their website in Q4 2024, explore collaborations with professionals in the sector in Q1 2025, and develop a policy position on fire safety in sheltered accommodation in Q1 2025. (AI summary)
View full response
Dear Professor Marks
Regulation 28 Report to Prevent Future Deaths – Inquest touching the death of Raymond Brattley
We write in response to your email dated August 2. Firstly, may I apologise for the substantial delay in responding to you. I am personally investigating why this happened and will take appropriate action. For future contact, you can approach me directly on this email address.
We are very saddened to read about the tragic death of Mr Brattley, and we thank you for approaching us.
Background The Royal Society for the Prevention of Accidents (RoSPA) is a charity in existence for over a century, we are concerned with the prevention of accidents across the full range of life, both in the UK and abroad. RoSPA has no regulatory role, or enforcement powers. We are therefore not in a place to comment on the circumstances of the incident, nor are we able to place blame or identify liability.
Actions and response from RoSPA We note that the report states the following actions/response for RoSPA:
Action should be taken In my opinion action should be taken to prevent future deaths and I believe you and your organisation has the power to take such action by highlighting to the widest audience, the risks of careless smoking in vulnerable individuals and indicating that the Fire Services would willingly provide assessment and advice for them. Your response You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday, September 27, 2024. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed.
Actions to be taken by RoSPA We acknowledge that as a national charity with substantial reach and reputation that we are a good place to educate the public and industry on accident prevention.
Given Mr Brattley’s history, and the fact that he was moved into sheltered accommodation, it seems reasonable and proportionate that the provider should have engaged the Fire Service for advice on the prevention of further fires RoSPA currently does not have specific guidance on fire prevention in sheltered premises, as this is generally an area where fire and rescue services have expertise. However, we acknowledge that fire incidents within sheltered premises would in many cases be classed as an ‘accident’. Therefore we will look to review our current advice education materials and activities around fire prevention in sheltered premises.
Action Timeline Reviewing and updating relevant information materials about fire safety in sheltered premises on our website
Q4, 2024 Exploring where we can work with professionals within the sheltered accommodation sector to promote fire awareness
Q1, 2025 Developing a policy position on fire safety in sheltered accommodation
Q1, 2025
We appreciate you bringing this tragic incident to our attention, and we would like to work towards preventing future deaths and accidents related to fires in sheltered premises.
Again, I sincerely apologise for the delay in responding to you.
Regulation 28 Report to Prevent Future Deaths – Inquest touching the death of Raymond Brattley
We write in response to your email dated August 2. Firstly, may I apologise for the substantial delay in responding to you. I am personally investigating why this happened and will take appropriate action. For future contact, you can approach me directly on this email address.
We are very saddened to read about the tragic death of Mr Brattley, and we thank you for approaching us.
Background The Royal Society for the Prevention of Accidents (RoSPA) is a charity in existence for over a century, we are concerned with the prevention of accidents across the full range of life, both in the UK and abroad. RoSPA has no regulatory role, or enforcement powers. We are therefore not in a place to comment on the circumstances of the incident, nor are we able to place blame or identify liability.
Actions and response from RoSPA We note that the report states the following actions/response for RoSPA:
Action should be taken In my opinion action should be taken to prevent future deaths and I believe you and your organisation has the power to take such action by highlighting to the widest audience, the risks of careless smoking in vulnerable individuals and indicating that the Fire Services would willingly provide assessment and advice for them. Your response You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday, September 27, 2024. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed.
Actions to be taken by RoSPA We acknowledge that as a national charity with substantial reach and reputation that we are a good place to educate the public and industry on accident prevention.
Given Mr Brattley’s history, and the fact that he was moved into sheltered accommodation, it seems reasonable and proportionate that the provider should have engaged the Fire Service for advice on the prevention of further fires RoSPA currently does not have specific guidance on fire prevention in sheltered premises, as this is generally an area where fire and rescue services have expertise. However, we acknowledge that fire incidents within sheltered premises would in many cases be classed as an ‘accident’. Therefore we will look to review our current advice education materials and activities around fire prevention in sheltered premises.
Action Timeline Reviewing and updating relevant information materials about fire safety in sheltered premises on our website
Q4, 2024 Exploring where we can work with professionals within the sheltered accommodation sector to promote fire awareness
Q1, 2025 Developing a policy position on fire safety in sheltered accommodation
Q1, 2025
We appreciate you bringing this tragic incident to our attention, and we would like to work towards preventing future deaths and accidents related to fires in sheltered premises.
Again, I sincerely apologise for the delay in responding to you.
Sent To
- Royal Society for the Prevention of Accidents
Response Status
Linked responses
1 of 1
56-Day Deadline
27 Sep 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 16th January 2024, I commenced an investigation into the death of Raymond Brattley, aged 71 years. The investigation concluded at the end of the inquest on 13th June 2024. The conclusion of the inquest was: ACCIDENT
Circumstances of the Death
These are set out in my summary and findings of facts which are attached. Raymond BRATTLEY was a heavy cigarette smoker, who on a number of previous occasions placed partly extinguished cigarette ends into a wastepaper bin in his flat, which subsequently caught fire, but these were successfully extinguished. On 8th January 2024, a fire resulted in his flat from careless smoking, which engulfed Mr Brattley resulting in him developing widespread full thickness burns to his entire body from which he rapidly died at the scene.
Action Should Be Taken
by highlighting to the widest audience, the risks of careless smoking in vulnerable individuals and indicating that the Fire Services would willingly provide assessment and advice for them.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.