Kevin Freely · Prevention of Future Deaths report

On 3rd July 2017 the court opened an investigation into the death of Kevin Freely. He had died on 12th October 2016.

The inquest was concluded on 7th June 2018.

The record of Inquest stated the following:

The medical cause of death found for the deceased was:

1a Cardiorespiratory arrest
1b Injuries sustained in a fire

II. Previous Stroke

Where, when and how, by what means and in what did he die:

The deceased was bedbound and immobile following a previous stroke. He had previously had a traumatic head injury in the past and a history of seizures had since been controlled with medication. At the time he died he had carers and lived at his home at ████████. He was known to smoke hand-rolled cigarettes and cannabis in bed. On 12th October 2016 his carer left him with a rolled-up cigarette and went on a two hour break away from the house. The deceased either suffered a seizure causing his cigarette, once lighted, to make contact with his bedclothes or otherwise he dropped his cigarette on his bedclothes. Whichever it was, a fire started in his bed area and it sadly caused his death on the same day, the deceased being unable to move from his bed to escape.

The Conclusion given was:

The deceased died in a fire at his home when his lighted cigarette came into contact with his bedclothes either due to an accident or a seizure.

The deceased was aged 61 when he died. He died at his home at ████████
████████.

The deceased had a history of heart disease, physical disability and drug and alcohol dependence with some mental health concerns.

He was being cared for in a bed with an airflow mattress at his home. He had had a stroke many years previously and was paralysed down his left side. He was doubly incontinent, bedbound and needed 24 hour care.

He was known to be a cigarette smoker and he used to smoke in bed. Despite his immobility and disabilities, he would have been able to light his own cigarette. He was on regular Morphine tablets and also smoked cannabis for pain relief.

I have heard that having an airflow mattress is essentially like kindling a fire, especially when used in conjunction with paraffin based emollient creams on a user’s skin. Such creams can accumulate and make the immediate environment to the patient more flammable.

The deceased had been having paraffin based emollient cream applied to his skin as part of his care. He had been alone when he set alight a cigarette and either had sustained a seizure or had otherwise just accidentally dropped the cigarette, but the cigarette caused his bed clothes to set alight. Sadly, the deceased died still lying in his bed.

The fire that occurred in this case was almost totally isolated to the first floor and particularly, the deceased’s bed and bedroom.

The NHS National Patient Safety Agency brought out a Rapid Response Report 4 on 26th November 2007 entitled “Fire hazard with paraffin based skin products on dressings and clothing”. I am concerned that this message within the 2007 Safety Report is not being heeded by patients and Care Organisations responsible for caring for patients in their own homes.