Vera Lillian Steel

PFD Report Historic (No Identified Response) Ref: 2013-0185
Date of Report 13 August 2013
Coroner Michael Burgess
Coroner Area Surrey
Response Deadline est. 8 October 2013
Coroner's Concerns (AI summary)
A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons or smocks to residents who smoke to prevent similar incidents.
View full coroner's concerns
The deceased who had full testamentary capacity, was either bedbound or in a wheel chair: She insisted on smoking: She was extremely frail and tried to light a cigarette using a match: She apparently managed to strike one but she then dropped it (the Iit match) into her lap. Her cotton night dress caught fire and she received bums_ In the course of evidence we received evidence how it is now possible to Obtain a fire protective apron or smock that could be wom or draped over the smoker SO that any such incident would result in the match (or a lit cigarette) buming out without any damage to the clothing or smoker__With many fatal domestic fires being caused by the_ heavy garden legs: lap King' College The

"incautious disposal 0f smoking products" this sont 0f pro-active clothing could be more widely available and those places (such as care homes) whose residents may include smokers should be encouraged to provide access to these protective measures_
Sent To
  • Care Quality Commission
  • South East England Fire and Rescue Service
Response Status
Linked responses 0 of 2
56-Day Deadline 8 Oct 2013
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
Circumstances of the Death
The deceased was a smoker. On Saturday 24 March 2012,she was taken onto the terrace of Glebe Nursing Home where she resided in order to smoke. She had refused to dress and was still in her night attire with a blanket over her She asked her carer to fetch a glass of brandy and whilst the carer was gone, the deceased attempted t0 light a cigarette using a match She apparently dropped the lit match into her causing a fire and resulting in severe burns Despite treatment by attending paramedics and the specialist burns unit at Hospital she died later that evening:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you ANDIOR your organisation have the power to take such action.
Related Inquiry Recommendations

Public inquiry recommendations addressing similar themes

Require fire safety strategy from registered fire engineer at Gateway 2
Grenfell Tower Inquiry
Vulnerable people fire risk Fire risk assessment failures
Require fire engineer calculations for fire spread and evacuation
Grenfell Tower Inquiry
Fire risk assessment failures Fire risk, vulnerable smokers
Review regulations for storing explosive materials in high-rise residential blocks
Ronan Point Inquiry
Vulnerable people fire risk Fire risk assessment failures
Out-of-school settings guidance update
Southport Inquiry
Fire risk assessment failures
Require external wall information for fire services
Grenfell Tower Inquiry
Fire risk assessment failures
Train fire personnel on external wall fire risks
Grenfell Tower Inquiry
Fire risk assessment failures
National guidelines for high-rise evacuations
Grenfell Tower Inquiry
Vulnerable people fire risk
LFB to review PN633 Appendix 1
Grenfell Tower Inquiry
Fire risk assessment failures
Require evacuation plans for high-rise buildings
Grenfell Tower Inquiry
Fire risk assessment failures
Require personal emergency evacuation plans (PEEPs)
Grenfell Tower Inquiry
Vulnerable people fire risk

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.