Fire risk, vulnerable smokers
Inadequate assessment and mitigation of fire risks posed by vulnerable heavy smokers in care settings.
56 items
6 sources
1 inquiry
Source spread
Where this theme appears
Fire risk, vulnerable smokers has been flagged across 6 independent accountability sources:
1 inquiry rec
36 PFD reports
1 committee rec
2 CQC actions
1 detention investigation rec
15 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
PFD Reports (36)
Vera Lillian Steel
Concerns: 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.
Overdue
Julie Ann Camm
Concerns: A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing to ensure installation and increasing the risk of death from fire.
Response (Leeds City Council): Housing Leeds will install hard-wired smoke detection in 40 properties and battery-powered detectors in remaining properties without detection equipment over the next 12 months, in consultation with West Yorkshire Fire …
Responded
Anthony Lapping
Concerns: Highly flammable insulation material in a Hotpoint fridge freezer caused rapid fire spread, severely reducing escape opportunities and highlighting an urgent need for manufacturing review.
Response (Indesit): The company outlines the safety standards in place at the time of manufacture and improvements made since. It describes assessments underway to reduce flammability further but describes constraints on introducing …
Responded
Amanda Richards
Concerns: The absence of domestic sprinkler systems in special accommodation, like Ms Richards', significantly increased the risk of death from fire.
Response (Whitefriars Housing): Whitefriars Housing states that they will participate in a serious incident review led by the West Midlands Fire Service, and will commission and pay for the installation of domestic sprinkler …
Responded
Santosh Muthiah
Concerns: The inability to identify appliance details after severe fire damage hinders accurate defect pattern recognition, and inconsistent information sharing among Fire & Rescue Services impedes product safety investigations.
Response (AMDEA): AMDEA's Technical Manager on Refrigeration together with industry safety specialists prepared a basic proposal for change to the international standard IEC 60335-2-24. This proposal was placed before the BSI committee …
Response (BSI): BSI Committees CPL/61 and PEL/33 reviewed the points raised and are submitting a proposal to the International Committee to add a warning about supply cords and portable socket-outlets to relevant …
Response (Forensic Sciences): The Society explains its role as a professional body for forensic science practitioners, noting that their reports are usually delivered directly to those who engaged them and may be sensitive …
Response (Chief Fire Officers Association): CFOA will engage proactively with DCLG to help develop the future IRS and the ease by which this type of information can be gathered, accessed and disseminated. CFOA will provide …
Response (Department for Business Innovation Skills): BIS will consider consistency of guidance and sharing of best practice as part of the independent review of consumer product recalls. The potential for a Code of Practice will also …
Responded
Robert Spring
Concerns: Inadequate communication channels failed to inform the Fire and Rescue Service about high-risk home oxygen users who smoked, preventing assessment for crucial safety equipment like smoke alarms and flame-retardant bedding.
Response (United Lincolnshire Hospitals NHS Trust): United Lincolnshire Hospitals NHS Trust has met with Lincolnshire Fire & Rescue and Air Liquide to agree a process for sharing information, formalized the discharge process, and included a documented …
Responded
Irene Hamilton-Parker
Concerns: Clothing made of easily flammable man-made fabrics poses a risk, and steps should be considered to reduce the flammability of manufactured or imported clothing.
Response (Department for Business Innovation and Skills): The Department for Business Innovation and Skills acknowledges concerns about clothing flammability but states that most clothing is flammable and reducing it would require flame retardants with their own risks. …
Responded
John Hills
Concerns: Paraffin-based emollient creams lacked fire hazard warnings on labels and prescriptions, and risks were not communicated to a known smoker, highlighting a gap in NPSA guidance for lower percentage creams.
Overdue
Andrew Coates
Concerns: An unsuitable wooden shed was licensed for fireworks storage, containing other combustibles and having deficient licensing that failed to specify types or designate a specific site, exacerbated by sketchy inspection records.
Response (Cumbria County Council): Cumbria County Council has provided training to Trading Standards Officers on firework storage, reviewed quality assurance procedures (incorporating minor amendments), and audited large firework stores, rectifying an issue with separation …
Responded
Christopher Holyoake
Concerns: E45 cream, a highly flammable paraffin-based product, lacked fire hazard warnings on its packaging and prescription, leading to a dangerous lack of awareness among carers and the deceased.
Response (Reckitt Benckiser Group Plc): The company will be submitting an application to the MHRA to update the labelling of several E45 products to include guidance on potential flammability. The warning to be added to …
Response (Chief Fire Officers Association and MHRA): CFOA has circulated the report to Chief Fire Officers/Chief Executives and other practitioners in the fire and rescue services and Chief Fire Officers/Chief Executives will ensure that the information and …
Response (NHS England): NHS Improvement have informed the editors of the BNF that the risk also applies to less concentrated aqueous based paraffin containing products, and the BNF will in future include a …
Responded
William Thompson
Concerns: A high-risk service user lacked a smoke detector in his bedroom; social workers failed to assess or address this significant fire safety risk.
Response (William Thompson): The Hackney Safeguarding Adults Board commissioned a Safeguarding Adults Review under the provisions of the Care Act 2014, which has twenty six recommendations for improving practice and procedures across all …
Responded
Sadie Peters, Joseph Peters and George Peters
Concerns: Inadequate awareness programmes exist for the importance of fitting and maintaining smoke detectors in mobile and static caravans, increasing fire safety risks.
Response (Peters): The Caravan Club will include a reminder of fire safety, specifically the need for smoke detectors, in their monthly members' magazine and other publications.
Response (Surrey Fire and Rescue Service): Surrey Fire and Rescue Service, working with partners, has visited identified mobile home sites in Surrey, conducting fire safety visits and fitting smoke and carbon monoxide alarms. They are planning …
Overdue
Steven Billington
Concerns: No specific concerns are detailed in the provided text.
Response (S Billington): The Minister offers condolences to the family and friends of Mr. Billington.
Response (Department for Communities and Local Government): The Department acknowledges the report and notes that current guidance requires isolators for fire alarm systems to be secured against unauthorised tampering, and suggests the system in question may have …
Responded
Ellen Kelly
Concerns: Residential fire safety is compromised by flat front doors lacking self-closing mechanisms and failing to meet 30-minute fire resistance standards, leading to rapid fire spread and trapping residents.
Response (London Borough of Camden): The London Borough of Camden has a programme to improve fire safety in council housing, including regular meetings with the Fire Service, fire safety works to 4,500 high priority housing …
Responded
Roy Lawton
Concerns: The deceased's dressing gown was highly inflammable regardless of fabric, raising concerns about product safety, the need for flammability warnings, or manufacturing improvements in clothing.
Response (MS): M&S expresses condolences and states that the Gown was compliant with all legal requirements. M&S goes significantly beyond the legal requirements in its flammability testing of adult dressing gowns.
Responded
Sheila Gaskin
Concerns: Despite an identified risk of smoking in bed, carers regularly assisted the deceased to smoke, due to a lack of management oversight and a clear prohibition policy.
Response (CSSIW): CSSIW cannot impose a blanket ban on care workers assisting service users to smoke, but will issue general guidance to care providers on assessing and mitigating health and fire risks …
Response (CQC): CQC acknowledges the concerns, notes the service falls under CSSIW jurisdiction, and states their current inspection process covers governance systems, supervision, and accident/incident reviews, but does not support a blanket …
Responded
Dorina Zangari
Concerns: Undermined fire safety measures, absent functioning fire detection, and an inadequate alternative escape route in maisonettes place residents at significant risk of death or injury from fire.
Overdue
Terence Penney
Concerns: A fatal fire resulted from a vapour leak in a relatively new domestic fridge, highlighting a potential widespread safety risk with similar units in circulation.
Overdue
Christopher Hart
Concerns: The housing provider failed to impose fire safety standards for tenant furniture and did not review sprinkler system installation, despite evidence of their life-saving potential.
Response (Johnnie Johnson Housing): Johnnie Johnson Housing notes the comments regarding resident safety but states no further action is required as the property was built to standard in 1999 and no high risk was …
Responded
Maureen Milton
Concerns: There is insufficient awareness among healthcare professionals and carers about the severe fire risk posed by petrol-based emollient creams, which impregnate clothing and accelerate burns.
Response (Department of Health and Social Care): The MHRA has convened a stakeholder group to design educational resources for healthcare professionals and the public, aiming to launch a toolkit in 2020 with a press release and stakeholder …
Response (National Institute for Health and Care Excellence): NICE acknowledges the concerns but states that overseeing medicine safety, product warnings, and running safety awareness campaigns do not fall within its remit; they refer to existing BNF guidance for …
Response (UK Health Security Agency): Public Health England reviewed the report but defers to the Medical and Healthcare products Regulatory Agency (MHRA) as the concerns relate to medicines.
Responded
Riley Holt, Keegan Unitt, Tilly-Rose Unitt and Olly Unitt
Concerns: Conventional smoke alarms may be ineffective for children under 16, particularly boys, suggesting mandatory fire suppression systems in all new properties, similar to Wales, should be considered.
Response (Ministry of Housing, Communities and Local Government): The Secretary of State acknowledges the deaths and states that the government is committed to building safety, including a review of smoke alarm standards.
Responded
Neil Barre
Concerns: Communication between Staffordshire Fire and Rescue Service and domiciliary care providers needs improvement to ensure awareness when clients are not using provided fire safety equipment.
Response (Staffordshire Fire and Rescue Service): Staffordshire Fire and Rescue Service will conduct a fatal fire review involving key partner agencies, sharing any multi-agency learning. The learning will be used to review prevention and partnership activity, …
Responded
Sylvia Griffiths
Concerns: Consideration should be given to fire and smoke alarms specifically designed for people with dementia, which could improve safety for this vulnerable group.
Response (Staffordshire Fire and Rescue Service): Staffordshire Fire and Rescue Service will conduct a fatal fire review of the case with partner agencies, share learning nationally, and incorporate findings into Olive Branch training sessions.
Responded
Kevin Branton, Richard Smith, Audrey Cook, Alfred Cook and Maureen Cook
Concerns: The absence of a national database for gas appliances hinders rapid identification and tracing of dangerous items. Lack of mandatory recording impedes urgent communication and tracing between stakeholders.
Response (MP BEIS): The Department for Business, Energy & Industrial Strategy (BEIS) has asked the Office for Product Safety and Standards (OPSS) to engage with manufacturers, retailers, consumer groups, and government bodies to …
Overdue
Darrell Spear
Concerns: Agencies failed to effectively manage identified self-neglect and hoarding risks, particularly fire hazards, due to poor inter-agency communication and a lack of clear strategy.
Overdue
Henry Boddy
Concerns: There is a gap in enforcement powers regarding fire risks in residential properties, specifically the risks of a fire load arising from hoarding behaviour.
Response (Home Office): The Home Office acknowledges concerns about fire risks from hoarding but suggests a multi-agency approach is more appropriate than enforcement under the Fire Safety Order. They highlight the role of …
Overdue
Pauline Allison
Concerns: Insufficient awareness among patients, families, and carers about the increased fire risk from flammable emollient creams, especially when combined with air mattresses, poses a significant safety concern.
Response (CCGs): NHS Brighton & Hove CCG, NHS East Sussex CCG, and NHS West Sussex CCG have reviewed preventable deaths messaging related to flammable products and are raising awareness of the risks …
Response (British Medical Association): The BMA acknowledges the concern about patient awareness of risks associated with emollient creams, but states they are not the appropriate organisation to address it. They suggest contacting the MHRA, …
Responded
Daphne Holloway and Ivy Spriggs
Concerns: Sprinkler systems are not mandatory for care homes with residents of limited mobility, and these buildings aren't classified as 'Higher Risk Buildings' based on occupant vulnerability, leaving them at elevated fire risk.
Overdue
Cedric Skyers
Concerns: The care home's smoking risk assessment for immobile residents fails to adequately address immobility risks, lacks clear guidance on safety equipment provision, and does not document refusal of professional advice.
Response (Lewisham Safeguarding Adults Board): Lewisham Safeguarding Adults Board commissioned a Safeguarding Adult Review in April 2016 with revised terms of reference and an expected conclusion in July 2017; the Board's annual report for 2017/2018 …
Response (CQC): The CQC is assisting the Fire Authority with a joint investigation and is planning to undertake a further unannounced comprehensive inspection of Manley Court in July 2017 to review documentation …
Response (BUPA): BUPA has revised its safe smoking assessment and smoking policy, including offering smoking aprons and pendant alarms to residents who smoke in the garden, and requiring supervision for those who …
Responded
Brian Harfield
Concerns: There's a critical lack of compulsory fire safety provisions, such as sprinklers, in extra care facilities for vulnerable, immobile residents, leaving them at significant risk of death from fires.
Response (Department for Levelling Up Housing and Communities): The Department for Levelling Up, Housing and Communities acknowledges the concerns regarding fire safety measures in extra care facilities and outlines existing regulations, guidance, and the role of the Building …
Responded
Mizanur Rahman
Concerns: A lack of British or European safety standards for lithium-ion e-bike batteries and chargers allows unsafe products to be sold and mixed, causing fires, thermal runaway, and multiple deaths.
Response (Product Safety and Standards): The Office for Product Safety and Standards has engaged with the London Fire Brigade and Tower Hamlets Trading Standards, established a multi-disciplinary safety study, commissioned research into battery safety, and …
Responded
Jill Brice
Concerns: Care residents are not consistently reminded to keep their emergency pendants close, posing a safety risk during emergencies like fires.
Response (CQC): The CQC states that the location where the death occurred was not registered with them and appears to fall outside the scope of registration and regulation by them. They have …
Response (CQC): The CQC states that the sheltered accommodation where the deceased resided is not registered with them and therefore not regulated by them, so they cannot comment on the specific concern …
Responded
Bobby Lee
Concerns: A significant rise in fires from faulty e-bike/e-scooter lithium-ion batteries and unsuitable chargers, often from inferior conversion kits and unregulated online sales, highlights the lack of specific safety standards.
Response (Product Safety and Standards): The government is part of a taskforce to establish the root causes of e-bike fires. A British Standard is being developed for businesses to use within 12-18 months and the …
Responded
Bernadette Faulkner
Concerns: The electricity meter's excessive height and placement behind an inwardly opening door created a significant safety risk for access, compounded by the lack of industry standards for meter accessibility.
Response (Energy Industry): Energy UK expresses condolences and notes that it does not represent all energy network companies. It outlines existing industry practices regarding meter placement, safety checks, and support for vulnerable customers, …
Response (Department of Health and Social Care): Ofgem introduced new rules in November 2023 restricting suppliers from involuntarily installing prepayment meters for specific vulnerable customers, and suppliers are now required to assess the safety of prepayment meters …
Responded
Raymond Brattley
Concerns: 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.
Response (Royal Society for the Prevention of Accidents): 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 …
Responded
Muhammad & Naemat Esmael
Concerns: Welsh housing legislation requiring only two hard-wired smoke alarms in rented properties is insufficient, as alarms failed to activate in a contained bedroom fire, posing a risk to life. Crucial items were also prematurely removed from the fire scene, hindering investigation into the cause.
Response (Mid and West Wales Fire and Rescue Service): Mid and West Wales Fire and Rescue Service supports increasing smoke alarm coverage to the highest standard in all new build premises in Wales and will support any proposals for …
Response (Welsh Government): The Welsh Government acknowledges the concern regarding smoke alarms and refers to the Renting Homes (Wales) Act 2016, which mandates landlords to ensure rented homes are fit for habitation and …
Responded
LGO / SPSO Decisions (15)
PSOW-202103888 — Cardiff Council
Ms A complained that Cardiff Council (“the Council”) had failed to maintain the flat she resided in. She stated that some work had been carried out over the past year but that there were still issues that required further attention. Ms A was unhappy with the written response she had …
PSOW (Public Services Om…
Local Government
Oct 2021
PSOW-202104624 — Linc Cymru Housing Association
Ms A complained about outstanding maintenance issues at her home address. She said that contractors had visited the property and informed her that some the issues are also affecting other residents on the development. The Ombudsman found that Ms A had submitted a previous complaint to his office which was …
PSOW (Public Services Om…
Housing
Oct 2021
PSOW-202103115 — Hafod Housing Association
Ms A, who was a tenant of Hafod Housing Association (“the Association”) complained about a delay in undertaking repairs at her home which she said was affecting her health and wellbeing. Consequently, she had also applied for a transfer although would preferably want to stay at the property. Ms A …
PSOW (Public Services Om…
Housing
Oct 2021
PSOW-202103137 — Valleys To Coast Housing
Ms A complained, on behalf of her mother, Mrs B, that Valleys to Coast Housing (“the Housing Association”) failed to take appropriate action to deal with a leaking roof at Mrs B’s home. Ms A was unhappy with the remedial patching works undertaken and said that the roof needed to …
PSOW (Public Services Om…
Housing
Oct 2021
PSOW-202207159 — Trivallis
Miss X complained that Trivallis had cancelled and rescheduled operative appointments and she still had outstanding repairs to her shower. The Ombudsman decided that there had been delays and oversights with the appointments and that Trivallis had closed its file before the repairs had taken place. She said this caused …
PSOW (Public Services Om…
Mar 2023
PSOW-202207603 — Cardiff Council
Mr L complained that the Council had failed to resolve the issue of damp and mould in his property and keep him updated with any progress. The Ombudsman decided that there had been a delay by the Council to rectify the issue and this had caused inconvenience and frustration for …
PSOW (Public Services Om…
Local Government
Mar 2023
PSOW-202303510 — Carmarthenshire County Council
Mrs G complained that Carmarthenshire County Council failed to undertake the necessary repairs to her flat. The Ombudsman found that whilst the Council had issued a Stage 1 complaint response it had failed to escalate Mrs G’s concerns to Stage 2 of its complaints process. She said that this caused …
PSOW (Public Services Om…
Local Government
Aug 2023
PSOW-202303088 — Trivallis
Mr E complained that Trivallis failed to action a roof repair which has been ongoing for over 6 months. The Ombudsman found that there had been a delay in Trivallis undertaking the repairs required. Furthermore, Trivallis had failed to provide regular and meaningful updates to Mr E. She said that …
PSOW (Public Services Om…
Aug 2023
PSOW-202302422 — United Welsh Housing Association
Ms A complained that United Welsh Housing Association (“the Housing Association”) had not responded to a complaint she had made to it about damp at her property. She complained that the damp in her home had been worsening and her attempts to get the Housing Association to rectify the issues …
PSOW (Public Services Om…
Housing
Sep 2023
21-004-788 — Southampton City Council
Summary: Mr X complained on behalf of Ms B and Mr C that the Council failed to take action to ensure their landlord completed remedial works to their private rented property within a reasonable time. We found the Council took appropriate action to ensure the landlord completed the required works …
LGO (Local Government & …
Housing
Upheld
May 2022
PSOW-202100263 — Bron Afon Community Housing Ltd
Mr X complained that the Housing Association had not replaced a carpet which had been damaged by a water leak at his property. Instead it had agreed to a give a financial payment which Mr X said was not sufficient to enable him to replace the carpet. The Ombudsman’s office …
PSOW (Public Services Om…
Housing
May 2021
PSOW-202006336 — Trivallis
Mr X complained that the Association had failed to start or complete any of the work to his property, as outlined in their complaint response to him dated 18 December 2020. In considering the complaint, the Ombudsman was concerned about the delays that Mr X had experienced, that the Association …
PSOW (Public Services Om…
May 2021
PSOW-202005311 — Valleys To Coast Housing
Mr X complained that Valleys To Coast Housing (“the Association”) had failed to complete the schedule of work required as part of an improvement notice that was issued by his local authority’s Environmental Health department, intended to resolve problems associated with damp at his house. The Association agreed to write …
PSOW (Public Services Om…
Housing
May 2021
22-011-599 — Stevenage Borough Council
Summary: We will not investigate Miss X’s complaint about the Council’s maintenance of trees near her property. There is not enough evidence of fault by the Council in its decision-making process to justify us investigating. The complaint is also late and there is no good reason for us to investigate …
LGO (Local Government & …
Environment And Regulation
Dec 2022
24-019-571 — Walsall Metropolitan Borough Council
Summary: We cannot investigate this complaint about disrepair in
LGO (Local Government & …
Housing
Apr 2025