Kenneth Brincombe
PFD Report
All Responded
All 2 responses received
· Deadline: 20 Oct 2018
Coroner's Concerns (AI summary)
Carers facilitated smoking for a high-risk patient without supervision, lacked training in fire safety assessment, and smoke detectors were not linked to emergency services, increasing fire risk.
View full coroner's concerns
_ Mr Brinicombe was aware that his smoking put him at a high risk of starting a fire. He wanted to continue smoking and had capacity to make this decision: However this could only be achieved if carers provided him with cigarettes and matches. They could not supervise him smoking: am concerned that: (1) There was an asst that because Mr Brinicombe wanted to smoke that the carers had no choice but to facilitate this despite putting Mr Brinicombe and his neighbours at risk of death by fire_ (2) In evidence the carer confirmed that the carers were responsible for maintaining a safe environment; but had no training in how to assess whether the house and the appliances were safe or whether posed a hazard: (3) Mr Brinicombe had received advice and had three smoke detectors fitted, however these would only alert Mr Brinicombe to the fire. The smoke detectors would not alert a fire station, and in Mr Brinicombe's level of disability he would be unable to take evasive action: Derriford Park, Derriford Business Park Plymouth, PL6 5QZ Tel 01752 204636 Fax from umption they fire
Responses
Sent To
- Devon County Council
Response Status
Linked responses
2 of 2
56-Day Deadline
20 Oct 2018
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 15 November 2016 an investigation was commenced into the death of Kenneth Arthur Brinicombe, 81 The investigation concluded at the end of the inquest on 25 August 2017. The conclusion of the inquest was ACCIDENT.
Circumstances of the Death
Mr Brinicombe was an 81 year old gentleman who suffered various health problems which rendered him immobile and significantly visually impaired. His one pleasure was smoking; however in light of his mobility and sight problems and his lack of manual dexterity he was at high risk of accidentally starting a fire. On 31 October 2016 those fears were realised_ Mr Brinicombe accidentally set fire to himself when smoking and died as a result of the burns he sustained.
Action Should Be Taken
Inmy opinion action should be_taken to prevent future deaths and believe Vou have the power to take such action (1) Confirm the process of undertaking risk assessments in the home of a vulnerable adult; who cannot ensure the safety of hislher environment;, and confirm the training the staff have to identify fire hazards. (2) Describe what measures should be taken when carers are asked to facilitate an activity which will endanger the lives of the individual concerned and others_ (3) Confirm whether in the future, where a vulnerable adult is at high risk of accidentally starting putting himself and others lives in danger; and unable to take any action if this occurs, that smoke detectors would be fitted that have a direct link to a station,
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.