Kevin O'Hara
23 Nov 2023 · Coroner Susan Ridge · Surrey
The coroner's concerns
1. inadequate smoke detection and careline monitoring
“the correct siting of smoke detection/alarm and careline monitor”
2. lack of risk assessment after ASC visit
“visit by ASC to review Mr [name redacted] at his flat on 23 January 2023 following concerns about his health and fire risk from smoking should have resulted in a risk assessment.”
3. absence of review and audit of Safe and Well Visits
“SFRS do not appear to have in place a system of review or audit by line managers or more experienced staff of completed Safe and Well Visits”
4. failure to conduct risk assessment after ASC visit
“the visit to Mr [name redacted] by ASC on 23 January 2023 should have resulted in a risk assessment”