A bedridden man died in Kingston after suffering a seizure and dropping a cigarette on to his bedclothes engulfing the room in a “predictable and preventable” fire. 

The incident was revealed in a Safeguarding Adult Report released by the council.

The 61-year-old man, known in the report only as SU, was largely bedbound and paralysed down his left side and required 24-hour care. He died at his home in New Malden in October 2016. 

A review into the incident last year found that there was an “inadequate” response by the agencies involved in SU’s care, particularly around fire safety advice. 

The London Fire Brigade confirmed in the report that SU was at risk of fire because he could not rescue himself and liked to smoke hand-rolled cigarettes and cannabis in bed. 

The smoke alarm did not work and there was no fire extinguisher easily accessible to SU. 

His carers also used a paraffin-based product on his skin. The review said that while an NHS report from 2007 warned about a fire hazard with paraffin-based skin products on dressings and clothing, none of the agencies involved in SU’s care were aware of this at the time of the incident. 

This meant that deposits from the cream would have been allowed to build up on his clothing and bedclothes.

The London Fire Brigade has previously said in a BBC report they believe there have been at least 28 fatal incidents linked to paraffin-based skin creams since 2010. 

The report concluded that “while it was SU’s choice to smoke in bed, there should have been an awareness of this risk across agencies. 

“Clear information on the risk he was taking should have been relayed to and discussed with him and incorporated in assessment, care and treatment planning. The Adult Social Care and Caremark care plans did not refer to a smoking risk or the need for supervision whilst smoking in bed. The Mental Health Recovery Support Team records do not refer to a fire risk in the household and the GP surgery had not recognised a fire risk.”

At no point did anybody involved in SU’s care refer him to the London Fire Brigade for a home safety check.

The Coroner’s inquiry into SU’s death found both the seizure and dropping the cigarette to cause the fire were contributory factors in SU death. While the seizure could not have been predicted or prevented, the inquiry said “the causation of the fire was predictable and preventable and there are clear lessons to be learned by involved agencies to improve systems and practice in risk management.”

However, it added, “there is clear evidence that agencies have already highlighted and made strides towards addressing the learning from this incident.”

The police also launched an inquiry into the incident, but this did not lead to any criminal charges. 

But what were the key recommendations in the report?

  • Train agencies involved in care (including pharmacies, carers and service users) on awareness of fire risk factors.
  • Smoke alarms should be checked in assessment and care planning tools.
  • Those receiving care should be referred for home safety checks, with priority given to those who cannot move easily and smoke in bed. 
  • Agencies should consider alternatives to emollient creams and consider support options such as providing smoke alarms, fire extinguishers, fire retardant aprons and bedding and sprinklers.

A Kingston Council spokesperson said: “The Kingston Safeguarding Adults Multi-Agency Board (KSAB) have learnt lessons from this sad and tragic case.  A thorough review by an independent practitioner was undertaken and their recommendations have being introduced.

“This includes GPs and Pharmacists being more aware of prescribing certain medications and creams which are at risk to fire safety. A monthly multi-agency meeting to discuss and review high risk cases and take action to minimise risk of harm. As well as including fire safety in assessments and referrals to London Fire Brigade for safety checks.”