UK Inquiry Tracker

Peter Moran

PFD Report All Responded Ref: 2019-0181

Date of Report 30 May 2019

Coroner Margaret Jones

Coroner Area Stoke-on-Trent & North Staffordshire

Response Deadline est. 8 November 2019

Community health care and emergency services related deaths Emergency services related deaths (2019 onwards)

Judiciary.uk Report PDF

All 1 response received · Deadline: 8 Nov 2019

Coroner's Concerns (AI summary)

Carers failed to properly turn off a cooker before removing knobs for a fire-risk patient, and the knob removal method itself was inadequate to ensure appliance safety.

View full coroner's concerns

(1) There had clearly been instructions given by the family that the deceased was a fire risk and they had agreed with carers they should switch off appliances and remove the cooker knobs, and place them out of reach of the deceased. The cooker had not been properly turned off by the carer before the knobs had been removed.

(2) Removal of knobs did not appear to be an appropriate method of making the appliance safe. ANDREW BARKLEY LL.B, Hon DUniv HER MAJESTY’S CORONER

for the Stoke-on-Trent and North Staffordshire Coroner’s Area CORONER’S CHAMBERS, 547 HARTSHILL ROAD, STOKE-ON-TRENT ST4 6HF Tel: (01782) 234777 Fax: (01782) 232074 Email: coroners@stoke.gov.uk

Responses

AR1 Homecare Ltd Other

Action Taken
The organisation provides staff training on fire awareness, uses risk assessment tools for client homes and staff induction, and has engaged a company for risk assessments and online fire training. They added a clause to their risk assessment that under no circumstances do they remove any knobs from appliances, and recommend the request of a Fire Officer to visit. (AI summary)

View full response

Dear Ms Jones In response to your report regarding the late Mr Peter Moran am informing you of the action taken by ARI Homecare, am not going to say there is no proposed action as it does not pay to be complacent; so we carry out regular reviews on each client as it is a continual learning process when dealing with people My concern which felt had to be introduced was observation and awareness; the fact that no one throughout the had picked up on the eye level grill in a small kitchen was on, the kettle is situated on the worktop right next to the cooker and everyone who had visited that and made a cup of tea had not noticed or felt the heat coming from the eye level grill. Thave attached photocopies of our procedures in which we deal with H & Safety in our client' $ homes. Document [ This is a Generic Risk Assessment we take when we visit any potential clients, the assessor will go through this, would like to your attention to page where we have added that under no circumstances do we remove any knobs from appliances, recommend the request of a Fire Officer to visit Document 2: Is a Risk Assessment Analysis Action we use for electric and any gas appliances Document 3: Is the training we provide to every member of staff; (a) Is a book on Fire Awareness in which staff have to read and fill in a questionnaire This is provided by CQM Learning, (b) Is a DVD which explains the reason and causes of fires and how easily it can happen- This is provided by Mulberry House. Document 4: Is an example Risk Assessment which we use for staff induction/ training in which we highlight areas of concern (see page 4) ARI Homecare have also signed up with a Company called Atlas/ Citation who offer Risk Assessments, online Fire Training and 24/7 advise on all aspects of Health & Safety: (Document 5) Company Registered and Postal Address: AR1 Homecare, 91 St Johns Road, Biddulph, Stoke on Trent; ST8 6LL. Tele: 01782 518229 Company No:: 8569315 CQC Registration 04/08/2013 AND day day draw and Reg

It is important to us that we carry out regular reviews on each client and staff are fully aware of procedures and empowering them to be aware of any risks within their environment. Once again, reiterate that you cannot be complacent but please be assured that we will continue to take all the necessary measures to increase awareness in the safety of our clients. Kind Regards Merrak Irene Merricks Director AR Homecare working

Sent To

AR1 Homecare Limited

Response Status

Linked responses 1 of 1

56-Day Deadline 8 Nov 2019

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 30/11/2018 I commenced an investigation into the death of Peter Moran. The investigation concluded at the end of the inquest 10th May 2019. The conclusion of the inquest was The deceased was 89 years of age and had a history of chronic obstructive pulmonary disease, diabetes, irregular heartbeat, dementia and limited mobility. He lived alone and had a care plan in place. Precautions had been taken to reduce the fire risks in the property. The carers had been instructed to remove knobs from the cooker after use and place them out of reach of the deceased. On 8th August 2017 a carer visited the deceased and cooked breakfast. The gas cooker grill element had not been fully turned off, leaving an almost invisible flame still burning when the carer left. The cooker knobs and lighter had been placed on top of a cupboard out of reach of the deceased. Other visitors during the evening did not notice the lighted grill. At around 3.00am on 9th August 2017 the deceased got out of bed. He noticed the grill was still ignited and used a taper to take a flame from the grill and attempted to light the gas fire in the lounge causing the plastic log effect to smoulder. The Fire and Rescue Service attended and found the deceased inside the property. The grill was alight and the cooker knobs and lighter were still on top of the cupboard. He was taken to the Royal Stoke University Hospital, Stoke-on-Trent where he died at 2.30 am on 19th August 2017. The medical evidence was that the cause of death was hospital acquired respiratory infection due to smoke inhalation with underlying chronic obstructive pulmonary disease and ischaemic heart disease.

Circumstances of the Death

See above.

Copies Sent To

3. (Staffordshire Fire & Rescue)