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Investigation and inquest
On 6th August 2014 I commenced an investigation into the death of Ian David Morley age 57. The investigation concluded at the end of the inquest on 14th May 2015. The conclusion of the inquest was in narrative form including the following words "...His death was clearly the result of an accident but the risk of the accident occurring was not adequately managed at the time".
Circumstances of the death
The deceased was a wheelchair bound resident in supported accommodation with a history of multiple sclerosis. His carers found him alight after, it is presumed, he dropped a cigarette onto the seat of his wheelchair which was covered by a towel rather than a fire retardant seat cover. His condition had deteriorated prior to his death.
Coroner’s concerns
1. The multiple sclerosis nurse who had been working with the deceased noted that his condition had deteriorated shortly before his death. This should have prompted a fresh risk assessment but it was not evident that it did, in fact, do so.
2. There was inadequate fire risk management at Greenrod Place
Information checked against the published report and official responses