James Golds · Prevention of Future Deaths report

On 1st October 2020 I commenced an investigation into the death of James Golds. The investigation concluded on the 21st July 2021 and the conclusion was one of accident. The medical cause of death was 1a Respiratory failure secondary to smoke inhalation; II 17% total body surface area burns, chronic obstructive pulmonary disease

James Frederick Golds lived at Flat ████████ Millom Court. He was vulnerable and had become increasingly confused prior to 28th September 2020. He was a known smoker and there had been concerns relating to how he managed the risks of smoking. On 28th September 2020 emergency services were called to the address for a reported fire. James Golds was rescued from his flat by the fire service. He was taken to Wythenshawe Hospital with significant fire related injuries. He deteriorated and died at Wythenshawe hospital from the complications of smoke inhalation. The cause of the fire was identified as an accident caused by a cigarette discarded whilst he was confused.

1. From the evidence before the court it was clear that Mr Golds presented a significant risk of accidentally starting a fire. He resided in accommodation occupied by vulnerable members of the community who needed some support to live independently. The Court heard that there was little guidance for facilities such as his about how the risk of fire should be managed and escalation of such risk.

2. In addition in relation to the design and fire prevention features for such accommodation the inquest heard that there was no statutory requirement for sprinkler systems. Smoke detectors were in the hallway areas of each flat but because of the way in which a cigarette related fire developed the detector would not be triggered until the fire was well established. This made it difficult to escape and increase the risk of the fire spreading further.