A retirement home manager made cups of tea for elderly residents instead of evacuating the building after a fire broke out, an inquest heard.

Irene Cockerton, 87, died after a fire at Gibson Court, Manor Road North, Hinchley Wood, in the early hours of September 30, 2011.

Marion De Beer

Since this report of the evidence stage of the inquest was published, Marion De Beer has contacted us to complain that our report suggests she was in some way responsible for the tragic death of Mrs Irene Cockerton and it does not reflect her evidence that  in grouping residents in the communal lounge she was following fire brigade instructions. This report was concerned with one day of evidence. We reported each stage of the inquest over several reports. We believe our complete contemporaneous reporting of the inquest, available since June 2014 here, does not suggest that Mrs De Beer was found culpable or negligent in any regard—the Coroner ruling that the death was accidental and her assessment of the risk consistent with the fire brigade's—and the Court receiving evidence that Mrs De Beer had been implementing her employer's "stay put" policy.

The fire started two doors from Mrs Cockerton’s home on the first floor of the warden-assisted accommodation and she was the only person not to reach safety.

Her body was found the following day in the wardrobe of her flat and a post-mortem examination revealed she died from inhalation of fumes, with toxicology tests showing 98 per cent saturation of carboxyhemoglobin in her blood.

Marion Debeer, former house manager of Gibson Court, who lived on site, told the inquest she was woken by the fire alarm at about 12.05am.

She said: “This was not that unusual because of the burnt toast syndrome which does happen in these buildings. I assumed it was the same thing.”

After going to the fire panel in her office, Ms Debeer realised there was a fire in flat 25, rented by Patricia Blair, and called 999 before getting residents, who had gathered in the first floor corridor, to go down to the communal lounge.

Ms Debeer said: “There was no smoke, there was no danger there. It seemed to be a minor event, a minor incident. There was no feeling of panic, I feel sure of that.”

The court also heard once in the communal lounge, Ms Debeer boiled the kettle and made cups of tea for residents before she noticed any smoke coming from the building.

She said: “When I looked out in the garden - that was when I first noticed the first bit of smoke. I opened the door in to the garden and went to investigate.

“At that point, I heard water pouring down from the direction and area where the fire had started.

“I knew it must have been coming from the fire brigade. That is when I started to feel panicky.

“At this point, I knew we were dealing with something serious. I immediately told the group in the lounge to move out to the car park and then began the evacuation procedure.”

Residents from the rest of the building were evacuated by Ms Debeer and fire crews and once outside, a role call was done.

It was then that Ms Debeer realised three “vulnerable” residents were not accounted for and fire crews entered the building to look for them.

Two residents were found and brought to safety, but they were unable to locate Mrs Cockerton.

Patricia Blair, whose home the fire began in, told the court she had been watching a Shirley Bassey concert on television on the night of the fire before getting into bed to watch the remainder of the programme on her bedroom television.

Breaking down into tears, Mrs Blair said: “This is affecting me. I will never forgive myself for this.

“I fell asleep while I was watching the programme and I hadn’t turned it off. I came to and it was on fire. The room was covered in smoke. The curtains were on fire, everything around me was on fire.”

Mrs Blair was able to get out of her flat while still in her pyjamas but told coroner Richard Travers she could not remember whether she closed the door to her flat but said the smoke had come out in to the corridor.

She also told the inquest the fire doors had not automatically closed when the fire alarm went off because she could see Marion Debeer, house manager, at the other end of the corridor.

Mrs Blair also told the court there were never fire drills at Gibson Court and fire policies were not well known.

She said: “The only thing we did know was in the event of any sort of problem was that we don’t use the lift.”

Paying tribute to Mrs Cockerton, who had dementia, Mrs Blair said: “Everybody loved her. She was lovely.”

Mrs Cockerton’s daughter, Ann Fox, also gave evidence at the inquest, telling the court her mother would have been unable to walk down stairs due to arthritis in her knees and was also frightened of using lifts alone. The inquest continues.