Recipient

Staffordshire Fire and Rescue Service

First report 11 Aug 2015•Latest report 17 Nov 2020

Recipient record

Reports, concerns and published responses

Local government · Fire and rescue service. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 3
Published responses: 67%
Concerns addressed: 2
Stated actions: 7

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

67%published responses found

7stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Staffordshire Fire and Rescue Service linked to the concerns in each report. Select any concern, action or position to view the source wording.

17 Nov2020
Staffordshire South
Concerns raised1
1. Insufficient communication about and use of fire/smoke alarms directed at people suffering with dementia
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Redevelop Olive Branch training to accommodate changing community needs.
  Stated completed
2. Action
  Feed the inquest findings into Olive Branch training, including guidance on fire and smoke alarms for people with dementia.
  Stated planned
3. Action
  Use Olive Branch training to improve communication with domiciliary-care groups and reinforce feedback about vulnerable people not using provided specialist equipment.
  Stated planned
AI-generated summary

Sylvia Ruth GRIFFITHS · 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

Sylvia Ruth GRIFFITHS, who had dementia and was known to wander from her home, was found dead at home on 27 October 2019 after being overcome by fumes from a fire caused by inappropriate use of an electric kettle. During the inquest, concern was raised about greater communication about and use of fire or smoke alarms particularly directed at people with dementia.

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 Staffordshire Fire and Rescue Service; that does not assign responsibility.
PFD Monitor interpretation
Insufficient communication about and use of fire/smoke alarms directed at people suffering with dementia
Wider context from the report
“During the course of the inquest a suggestion was made that there can be fire/smoke alarms that are particularly directed at people suffering with dementia. It was mentioned that Staffordshire Fire and Rescue Service may well have links with groups helping the demented and that there could be greater communication about and use of such alarms. ”
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
Redevelop Olive Branch training to accommodate changing community needs.

Verbatim wording from the response
“Staffordshire Fire and Rescue Service work closely with partner agencies and Olive Branch training has recently been redeveloped to accommodate our ever changing community needs. The findings from the investigation into the death of Sylvia Griffiths and Neil Barre will be fed into these training sessions, particularly the availability and use of fire/smoke alarms that are designed for people suffering with dementia. These training sessions will also be used to improve communication with groups who provide domiciliary and reinforce feedback regarding people who may not be using the special equipment provided to them.”

Source location
2020-0238-Response-from-Staffordshire-Fire-and-Rescue-Service-Redacted.pdf
Page 2 · response
Published 24 December 2020
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
Feed the inquest findings into Olive Branch training, including guidance on fire and smoke alarms for people with dementia.

Verbatim wording from the response
“Staffordshire Fire and Rescue Service work closely with partner agencies and Olive Branch training has recently been redeveloped to accommodate our ever changing community needs. The findings from the investigation into the death of Sylvia Griffiths and Neil Barre will be fed into these training sessions, particularly the availability and use of fire/smoke alarms that are designed for people suffering with dementia. These training sessions will also be used to improve communication with groups who provide domiciliary and reinforce feedback regarding people who may not be using the special equipment provided to them.”

Source location
2020-0238-Response-from-Staffordshire-Fire-and-Rescue-Service-Redacted.pdf
Page 2 · response
Published 24 December 2020
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
Use Olive Branch training to improve communication with domiciliary-care groups and reinforce feedback about vulnerable people not using provided specialist equipment.

Verbatim wording from the response
“Staffordshire Fire and Rescue Service work closely with partner agencies and Olive Branch training has recently been redeveloped to accommodate our ever changing community needs. The findings from the investigation into the death of Sylvia Griffiths and Neil Barre will be fed into these training sessions, particularly the availability and use of fire/smoke alarms that are designed for people suffering with dementia. These training sessions will also be used to improve communication with groups who provide domiciliary and reinforce feedback regarding people who may not be using the special equipment provided to them.”

Source location
2020-0238-Response-from-Staffordshire-Fire-and-Rescue-Service-Redacted.pdf
Page 2 · response
Published 24 December 2020
Open published response
17 Nov2020
Staffordshire South
Concerns raised1
1. Failure to communicate domiciliary care recipients’ non-use of provided fire-safety equipment to the fire and rescue service
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Neil BARRE · 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

Neil Barre died at Queen Elizabeth Hospital in Birmingham on 11 September 2020 from burns sustained in a fire at his home in Cannock after he dropped a cigarette while smoking in bed. During the inquest, concern was raised about Staffordshire Fire and Rescue Service being informed when people receiving domiciliary care are not using special fire-safety equipment provided to them, and about communication with care-providing groups.

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 Staffordshire Fire and Rescue Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate domiciliary care recipients’ non-use of provided fire-safety equipment to the fire and rescue service
Wider context from the report
“During the course of the inquest a suggestion was made that it may be helpful for Staffordshire Fire and Rescue Service to be aware of when those receiving domiciliary care are not using special equipment (such as fire retardant blankets) that are provided to them. Staffordshire FARS may well have links with groups providing care and there could be greater use of communications with such groups. ”
Open source report
11 Aug2015
West Sussex
Concerns raised5
1. Failure to review and address fire risks of lower-paraffin emollient creams
2. Lack of community information about paraffin-emollient ignition risk
3. Fire hazard from paraffin-based emollients contacting clothing or dressings
1. Failure to consider paraffin-emollient fire risk when prescribing
2. Failure to communicate paraffin-emollient fire risk to patients
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

John Hills · 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

John Hills, a resident of a nursing home, suffered fatal burns after his clothing and blankets caught fire while he was smoking in the conservatory. The report raised concerns about the failure to ensure he was wearing his fire-retardant apron and about insufficient awareness, communication and prevention of the fire risks associated with paraffin-based emollient creams such as Cetraben, particularly in community care settings.

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 Staffordshire Fire and Rescue Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to review and address fire risks of lower-paraffin emollient creams
Wider context from the report
“(5) The NPSA carried a Rapid Response Warning (and report) on 26 November 2007 providing background and recommendations on the use of paraffin based products, but focused (as does the BNF) on (non-proprietary emollient preparations, specifically) emulsifying ointments or 50% plus paraffin content emollients. It is not clear whether this has been recently reviewed or whether the potential risk of lower % paraffin content creams has been considered and addressed. ”
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 Staffordshire Fire and Rescue Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of community information about paraffin-emollient ignition risk
Wider context from the report
“(7) Cetraben and Diprobase are proprietary emollient preparations in wide application in non-hospital environments, notably care homes, but also in private nursing and home care. It appears that there is little information conveyed or publicised about the potential risk of ignition/fire outside of hospitals or other clinical treatment areas, particularly where the cream is in frequent application and clothing (or bedding) has a high risk of becoming soaked or soiled by repeated application and contact. (8) I am concerned about the potential risks associated with Cetraben (and associated lower % creams) and the level of awareness, communication and prevention of such risks in the community. I believe this should be considered, the risks assessed and action taken, as appropriate. ”
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 Staffordshire Fire and Rescue Service; that does not assign responsibility.
PFD Monitor interpretation
Fire hazard from paraffin-based emollients contacting clothing or dressings
Wider context from the report
“(2) Diprobase emollient cream (the next ‘greasy’ preparation product and next step up from Cetraben) contains 21% paraffin content (15% white soft paraffin and 6% liquid paraffin) but 7.2% alcohol, and carries a fire hazard warning on prescription: ‘Dressing and clothing in contact with this product are easily ignited by a naked flame – Keep away’ (the product bottle itself has not been examined for warnings during the course of my enquiries). (3) The British National Formulary does not list either product specifically as being flammable, but does contain a general warning for paraffin based emollients that reads: “Fire hazard with paraffin-based emollients: Emulsifying ointment or 50% liquid paraffin and 50% white soft paraffin ointment in contact with dressings and clothing is easily ignited by a naked flame. The risk is greater when these preparations are applied to large areas of the body, and clothing or dressings become soaked with the ointment. Patients should be kept away from fire or flames and not to smoke when using these preparations. The risk of fire should be considered when using large quantities of any paraffin-based emollient” ”
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 Staffordshire Fire and Rescue Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider paraffin-emollient fire risk when prescribing
Wider context from the report
“(4) Mr Hills was clearly recorded (in his medical notes) as being a chronic smoker with acute bronchitis. He was also recorded as being a pipe smoker (in his medical records on 13/10/14) yet had a repeat prescription for Cetraben 500 gram being recorded on 11/09/14. There is nothing to evidence that any risk was considered or communicated by either the GP surgery or the prescribing pharmacy. ”
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 Staffordshire Fire and Rescue Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate paraffin-emollient fire risk to patients
Wider context from the report
“(4) Mr Hills was clearly recorded (in his medical notes) as being a chronic smoker with acute bronchitis. He was also recorded as being a pipe smoker (in his medical records on 13/10/14) yet had a repeat prescription for Cetraben 500 gram being recorded on 11/09/14. There is nothing to evidence that any risk was considered or communicated by either the GP surgery or the prescribing pharmacy. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised1

Insufficient communication about and use of fire/smoke alarms directed at people suffering with dementia

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure to communicate domiciliary care recipients’ non-use of provided fire-safety equipment to the fire and rescue service

Concerns raised5

Failure to review and address fire risks of lower-paraffin emollient creams

Lack of community information about paraffin-emollient ignition risk

Fire hazard from paraffin-based emollients contacting clothing or dressings

Failure to consider paraffin-emollient fire risk when prescribing

Failure to communicate paraffin-emollient fire risk to patients

Actions described in response 3