Thomas GODDERIDGE · Prevention of Future Deaths report

On 3 March 2023 I commenced an investigation into the death of Thomas GODDERIDGE. The investigation concluded at the end of the inquest. The conclusion of the inquest was:

Accidental death.

1a) Smoke Inhalation in combination with Chronic Obstructive Pulmonary Disease and Ischaemic Heart Disease

1b)

1c)

II)

Thomas Godderidge was 85 years old. He lived at ████████, Carlisle. Mr Godderidge was frail and suffered from short-term memory loss. On 16th February 2023 a fire broke out at Mr Godderidge's home. He died as a result of smoke inhalation.
Prior to Mr Godderidge's death repeated concerns had been raised about his risk of causing a fire. He repeatedly discarded lit cigarettes and had the habit of cutting paper into strips, which proved a ready source of fuel for a fire.

(1) During the inquest I heard from the carers who worked with Mr Godderidge. They reported to me that when concerns are raised about a service-user's capacity there is not reliable and routine liaison between Adult Social Care and the care providers. I am concerned that this gives rise to a risk of future deaths. Care workers are very likely to see a service user more often than others. They have a particularly valuable perspective as to a person's capacity. If their observations are not being considered then opportunities to provide care to vulnerable people may well be missed.
(2) Mr Godderidge's carers also reported to me that in their experience consideration of capacity by Adult Social Care does not always reflect the possibility that a person's capacity may be variable and fluctuating. I am concerned that this gives rise to a risk of future deaths if a person is considered on a 'good day' without understanding that their presentation fluctuates substantially over time.