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Investigation and inquest
On 30/11/2018 I commenced an investigation into the death of Peter Moran. The investigation concluded at the end of the inquest 10th May 2019. The conclusion of the inquest was The deceased was 89 years of age and had a history of chronic obstructive pulmonary disease, diabetes, irregular heartbeat, dementia and limited mobility. He lived alone and had a care plan in place. Precautions had been taken to reduce the fire risks in the property. The carers had been instructed to remove knobs from the cooker after use and place them out of reach of the deceased. On 8th August 2017 a carer visited the deceased and cooked breakfast. The gas cooker grill element had not been fully turned off, leaving an almost invisible flame still burning when the carer left. The cooker knobs and lighter had been placed on top of a cupboard out of reach of the deceased. Other visitors during the evening did not notice the lighted grill. At around 3.00am on 9th August 2017 the deceased got out of bed. He noticed the grill was still ignited and used a taper to take a flame from the grill and attempted to light the gas fire in the lounge causing the plastic log effect to smoulder. The Fire and Rescue Service attended and found the deceased inside the property. The grill was alight and the cooker knobs and lighter were still on top of the cupboard. He was taken to the Royal Stoke University Hospital, Stoke-on-Trent where he died at 2.30 am on 19th August 2017. The medical evidence was that the cause of death was hospital acquired respiratory infection due to smoke inhalation with underlying chronic obstructive pulmonary disease and ischaemic heart disease.
Circumstances of the death
See above.
The published report provides this section by reference to another part of the report.
Coroner’s concerns
(1) There had clearly been instructions given by the family that the deceased was a fire risk and they had agreed with carers they should switch off appliances and remove the cooker knobs, and place them out of reach of the deceased. The cooker had not been properly turned off by the carer before the knobs had been removed.
(2) Removal of knobs did not appear to be an appropriate method of making the appliance safe.
