May 10, 2019

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In Court

Pensioner’s death ‘could have been avoided’

A company which ran a South London care home has been fined more than £100,000 for breaching fire safety regulations after a pensioner died in their care.

Gold Care Consultancy Ltd was sentenced at Southwark Crown Court after pleading guilty to two offences under the Regulatory Reform (Fire Safety) Order 2005.

In January 2015, staff at Wood House Care Home were doing night time checks around the building when they heard cries for help from 78-year-old Rosina McDonald. They discovered a fire in her room. She suffered from severe burns and sadly died from her injuries.

London Fire BrigadeFollowing the fire, London Fire Brigade fire investigators found a series of serious safety concerns at the care home. The fire risk assessment for the premises was outdated and overdue for review.

The fire risk assessment failings included:

  • Not adequately reflecting the premises (it referred to a smoking room which no longer existed);
  • Not adequately reflecting the ‘no smoking’ policy in place at the premises;
  • Not considering the risk posed by individual smokers.

The care home was closed shortly after the fire.

Emollient cream

Mrs McDonald suffered a stroke in 2012 and had severe cognitive impairment as a result. Health professionals also highlighted she was at risk of being disorientated. Following the blaze, fire inspectors found two modified lighters in her room at the care home which allowed larger flames and may not have extinguished the flame when released.

The elderly resident was also prescribed emollient cream to be applied twice daily. The emollient cream contained 50% flammable ingredients.

The Brigade has issued a warning about using emollient cream, particularly for vulnerable people who smoke and have mobility issues. A small spark can quickly lead to a serious blaze if flammable emollients seep into dressings, clothing and bedding. This presents a real concern for people who are less able to escape if a fire takes hold, says the Brigade.

London Fire Brigade’s Assistant Commissioner for Fire Safety, Dan Daly said: “The fire risk assessment did not adequately reflect the fact that Mrs McDonald was at serious risk in the event of a fire. She was a resident who smoked and had severe cognitive impairment.

“Not only did she have lighters but she also had flammable ointments applied to the skin. These were serious breaches of fire safety and measures to safeguard the wellbeing of this resident could have been put in place easily and quickly and at little cost.

“Carers need to look at the individual needs of the people they look after and incorporate fire risk into the care planning process.

A person centred fire risk assessment is essential. If this had been in place then this tragic case could have avoided.”

Gold Care Consultancy was fined £90,000 plus £15,000 in costs at Southwark Crown Court.


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