the course of the inquest the evidence revealed a matter giving rise to concern that in my opinion means that there is still a risk that future deaths will occur unless action is taken: In the circumstances it is my statutory to report to you: The NHS National Patient Agency brought out a Rapid Response Report 4 on November 2007 entitled "Fire hazard with paraffin based Skin products on-doessings and clothing" am concerned that the message within the 2007 Report is not being heeded by patients and Care Organisations responsible for for patients in their own homes. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths Whilst [ acknowledge that everything has to viewed proportionately, and further; it is human right of a person to choose to smoke in their bed, I am concerned that all patients in such circumstances as the deceased (that is: immobile in a bed with an airflow mattress, having paraffin based emollient cream applied to his skin and smoking cigarettes whilst in bed), are made aware of the risks. Further; it is important that the carers take advice from the Fire Services in respect of regular washing (in a biological detergent) the Iinen and bed-clothes of a patient where paraffin emolliend creams are used to avoid the build-up of paraffin based emollients Care organisations must at the very least remind themselves about this Report If there are that are not following its advice, should take heed immediately as patients are being put at risk
3. The London Fire Brigade witnesses remind uS all that risk assessments and smoke detectors also play a very important role. Here, no risk assessment was done and one smoke detector in this house was an essential part and one did not operate when checked after the Lam sending this report to the Home Officer Fire Office too. This is to lodge my support for more promotion/advertisement of the facts in this Safety Report Patients themselves may not be aware of the risks posed with combining cigarette smoking in bed; air flow mattresses and the use of paraffin based emollient creams The three together create & specific and very real risk of injury in a fire and, with this invariably disabled/debilitated group of patients, death. Therefore, any resources spent on broadcasting these risks to patients is encouraged Further; to assist in the education of patients and Care Organisations, I am told that the use of fire retardant aprons and fire retardant bedding may reduce the risk of a death by fire with this group of patients who choose to continue to smoke in such an environment: YOUR RESPONSE During duty Safety 26th Safety caring regular being any they missing fire . Safety

You under a duty to respond to this report within 56 of the date of this are report; namely by 30th 2018_ I, the coroner; may extend the period Your must contain details of action taken Or proposed to be taken; feouothe tinetable fOr action: Otherwise you must why no action is setting proposed: If you require any further information Or assistance about the case; please contact the Coroner Officer_ and COPIES and PUBLICATION Ihave sent a copy of my report to the following Interested Persons: The deceased's family Caremark, Kingston London Fire Brigade. [am also under a to send the Chief Coroner a copy of yOur response The Chief Coroner may either or both in a complete Or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me; the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner DATE SIGNED BY CORONER 7th June 2018 days July ` explain out duty publish