Lewisham Safeguarding Adults Board

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First report 10 May 2017•Latest report 10 May 2017

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
3

Across all linked responses

Stated actions
4

Described in responses

Concerns and recipient responses

Statements from Lewisham Safeguarding Adults Board linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Inner South London

    AI-generated summary

    Cedrick Sykers · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Cedrick Sykers, a hemiplegic nursing-home resident who could not stand, reposition himself or propel his wheelchair, died in hospital after his clothes caught fire while he was smoking unsupervised in a garden. The report identified concerns about insufficient recognition and mitigation of the risks faced by immobile residents who smoke and cannot summon help, including the lack of clearly documented requirements for supervision, smoking aprons and alarm pendants.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lewisham Safeguarding Adults Board; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to document required smoking-risk mitigations and responses to their refusal

    Wider context from the report

    “The management of the Care Home and its owners, BUPA, have undertaken a thorough investigation and implemented a detailed Action Plan which has reduced many of the risks to life of accidental fires from resident’s smoking identified in the inquest. But one area remains a concern. BUPA corporate guidance indicated, at the time of Mr Skyer’s death and now, that residents who wish to smoke must have risk assessments with their abilities, dependencies and special requirements taken into account. The concern relates to the process of mitigating the risks from personal risk assessment of immobile patients. A new safe smoking risk assessment form has been introduced, which requires assessment of safely lighting and smoking a cigarette now to be recorded. The only new question to be asked which would score a concern for a resident such as Mr Sykers, in a wheelchair, is one as to whether the resident has any difficulty in balance. If that is recorded as yes, the process requires the documentation of the steps to be taken to limit associated risks. Nowhere is the risk associated with immobility specifically recognised, yet patients who are immobile and smoke in bed are required to be supervised. A BUPA Fire Risk Advisor told the court that he would recommend the same requirement should be made for those who are immobile but smoking elsewhere. The present policy appears to leave the nurse with the discretion as to what may be inserted into the plan. A BUPA manager informed the court that residents would be offered an apron and alarm pendant. This was not apparent in the documentation. It was not documented that a person who declined these would be expected to accept supervision, nor the importance of these for someone who is completely immobile. If this too was declined, it would seem that if the resident insisted in continuing to smoke without supervision or apron, consideration should be given as to whether this should be recorded as being a choice against professional advice. Reviewing all the evidence, including the variation in skills of nurses in smoking risk assessment and particularly noting the fire investigator’s evidence that the resident’s clothes can be completely consumed by fire in two minutes, the mitigation of risks of death to those who smoke outside in BUPA homes and are immobile and cannot summon help seem to have not been sufficiently recognised. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lewisham Safeguarding Adults Board; that does not assign responsibility.

    PFD Monitor interpretation

    Variation in nurses’ skills in smoking risk assessment

    Wider context from the report

    “The management of the Care Home and its owners, BUPA, have undertaken a thorough investigation and implemented a detailed Action Plan which has reduced many of the risks to life of accidental fires from resident’s smoking identified in the inquest. But one area remains a concern. BUPA corporate guidance indicated, at the time of Mr Skyer’s death and now, that residents who wish to smoke must have risk assessments with their abilities, dependencies and special requirements taken into account. The concern relates to the process of mitigating the risks from personal risk assessment of immobile patients. A new safe smoking risk assessment form has been introduced, which requires assessment of safely lighting and smoking a cigarette now to be recorded. The only new question to be asked which would score a concern for a resident such as Mr Sykers, in a wheelchair, is one as to whether the resident has any difficulty in balance. If that is recorded as yes, the process requires the documentation of the steps to be taken to limit associated risks. Nowhere is the risk associated with immobility specifically recognised, yet patients who are immobile and smoke in bed are required to be supervised. A BUPA Fire Risk Advisor told the court that he would recommend the same requirement should be made for those who are immobile but smoking elsewhere. The present policy appears to leave the nurse with the discretion as to what may be inserted into the plan. A BUPA manager informed the court that residents would be offered an apron and alarm pendant. This was not apparent in the documentation. It was not documented that a person who declined these would be expected to accept supervision, nor the importance of these for someone who is completely immobile. If this too was declined, it would seem that if the resident insisted in continuing to smoke without supervision or apron, consideration should be given as to whether this should be recorded as being a choice against professional advice. Reviewing all the evidence, including the variation in skills of nurses in smoking risk assessment and particularly noting the fire investigator’s evidence that the resident’s clothes can be completely consumed by fire in two minutes, the mitigation of risks of death to those who smoke outside in BUPA homes and are immobile and cannot summon help seem to have not been sufficiently recognised. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lewisham Safeguarding Adults Board; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise immobility and require supervision in smoking risk assessments

    Wider context from the report

    “The management of the Care Home and its owners, BUPA, have undertaken a thorough investigation and implemented a detailed Action Plan which has reduced many of the risks to life of accidental fires from resident’s smoking identified in the inquest. But one area remains a concern. BUPA corporate guidance indicated, at the time of Mr Skyer’s death and now, that residents who wish to smoke must have risk assessments with their abilities, dependencies and special requirements taken into account. The concern relates to the process of mitigating the risks from personal risk assessment of immobile patients. A new safe smoking risk assessment form has been introduced, which requires assessment of safely lighting and smoking a cigarette now to be recorded. The only new question to be asked which would score a concern for a resident such as Mr Sykers, in a wheelchair, is one as to whether the resident has any difficulty in balance. If that is recorded as yes, the process requires the documentation of the steps to be taken to limit associated risks. Nowhere is the risk associated with immobility specifically recognised, yet patients who are immobile and smoke in bed are required to be supervised. A BUPA Fire Risk Advisor told the court that he would recommend the same requirement should be made for those who are immobile but smoking elsewhere. The present policy appears to leave the nurse with the discretion as to what may be inserted into the plan. A BUPA manager informed the court that residents would be offered an apron and alarm pendant. This was not apparent in the documentation. It was not documented that a person who declined these would be expected to accept supervision, nor the importance of these for someone who is completely immobile. If this too was declined, it would seem that if the resident insisted in continuing to smoke without supervision or apron, consideration should be given as to whether this should be recorded as being a choice against professional advice. Reviewing all the evidence, including the variation in skills of nurses in smoking risk assessment and particularly noting the fire investigator’s evidence that the resident’s clothes can be completely consumed by fire in two minutes, the mitigation of risks of death to those who smoke outside in BUPA homes and are immobile and cannot summon help seem to have not been sufficiently recognised. ”
    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Hold learning and service development seminars and produce and circulate a briefing note to disseminate review learning for service, policy and practice transformation.

    Verbatim wording from the response

    “Learning and service development seminars will also be held, and a briefing note produced and circulated, to ensure that the lessons learned through the review lead to service, policy and practice transformation where appropriate.”

    Source location

    Response from Lewisham Safeguarding Adults Board
    Page 3 · response
    Published 7 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct an independent Safeguarding Adult Review into the death, examining events, care, risk management, practice standards, causes and remedial actions.

    Verbatim wording from the response

    “1. The Lewisham Safeguarding Adults Board (LSAB) has determined that the death of Mr CS satisfies the Care Act 2014 (Section 44) statutory requirement for a Safeguarding Adult Review (SAR). The LSAB has decided that an overview model, which documents events and analyses their causes, is appropriate in the circumstances; thereby satisfying the statutory guidance that the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined.”

    Source location

    Response from Lewisham Safeguarding Adults Board
    Page 1 · response
    Published 7 October 2022

    Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026