Mr Brian MacLean · Prevention of Future Deaths report

I resumed and concluded the inquest into the death of Mr Brian MacLean on 6 September 2017 and recorded that he died from:

1a Smoke inhalation

II Alcohol toxicity

Somewhat unusually I recorded a conclusion of – Alcohol related

The deceased was born on 20 December 1957 and had developed over a number of years a significant alcohol consumption problem. He was also a regular smoker of cigarettes. He had lost touch largely with his family and had spent periods of time in private rented accommodation and more recently at a Salvation Army Hostel.

He took up occupation of Flat 35 George Thomas Court, Harpurhey, Manchester, on 26 November 2012 and lived on his own.

This accommodation is owned by Great Places Housing Association (GPHA).

He was allocated a support worker who discovered that he had no telephone or access to email and was only ever intermittently available to see his support worker.

The deceased was not in employment and was in receipt of state benefits. It seems that a referral was made to the Manchester City Council Adult Social Services Department on 26 January 2016. His support worker had discovered that he had no household appliances other than a microwave in which he cooked all of his meals and had little in the way of possessions. He claimed to have a nursing background and a long term chronic bowel condition. This apparently resulted in the local authority writing a letter to the deceased asking if he required any help or support and when they received no reply the case was closed.

Greater Manchester Fire and Rescue Service (GMFRS) regularly work with housing providers to facilitate the referral of persons at increased risk of suffering a fire. No such referral was made in respect of the deceased.

The deceased was registered with a GP at the Singh Medical Practice but was an infrequent attender, but with a diagnosis of Crohn’s Disease and a long term alcohol problem. The fire had self-extinguished.

On 19 March 2016 the deceased had consumed a very excessive amount of alcohol and had been smoking whilst sitting in his sofa. A fire started on the sofa which created a great deal of noxious smoke. It also caused him to suffer a burnt leg. When the alarm was raised and GMFRS attended he was found in the hall way having apparently made attempts to remove his trousers.

He died as a result of smoke inhalation contributed to by alcohol toxicity. All other sources of ignition for the fire apart from a discarded cigarette were ruled out.

The premises did not have an automatic water sprinkler system.

Statistically a significant proportion of fatal fires involve single males living on their own having drink, drugs or mental health problems. Since the incident GMFRS have worked with GPHA to deliver fire prevention staff awareness training and to introduce them to the new ‘Safe and Well Visits’ that GMFRS are now offering. A copy of the record of inquest and the evidence accompanies this report.

This report is being distributed to MCC Housing Department with a request that they consider it internally but also that they distribute it to all other Housing Associations within Greater Manchester. In addition to the NHS and the GP MPC.

1. That Social Services did not take a more proactive role in pursuing any referral and understanding the risks presented by the deceased. This requires joined up thinking and working with GPs, the NHS locally, the housing provider and finally GMFRS.

2. There was no identification of the deceased as being potentially at risk of a fire in his premises and no referral to GMFRS.

3. There was no process for GPHA to automatically consider fire risks and prevention and make referrals to GMFRS for safe and well visits.

4. It is clear that GPHA did not have an automatic water suppression system (sprinklers) that could be fitted to properties which comprise blocks of flats and or for individuals at high risk. In addition appropriate smoke alarms and other assistive technology could have been installed.

5. The recipients of this report would be well advised to read and digest the detailed GMFRS Fire Investigation Report and its recommendations which are wholly endorsed by the court.