Kevin Stephen O’Hara · Prevention of Future Deaths report

An inquest into the death of Kevin Stephen O’HARA was opened on 7 March 2023, resumed on 2 November 2023 and concluded on 22 November 2023.

The medical cause of death was:

1a. Inhalation of fire fumes and burns.

With respect to where, when and how Mr O’Hara came by his death it was recorded at Box 3 of the Record of Inquest as follows:

Kevin Stephen O’Hara died in a fire in the early morning of 7 February 2023 at his home in Frimley, Camberley. He lived on his own and was bedbound in his living room. He was known to smoke in bed and it is more likely than not that the fire started because a lit cigarette fell onto a mattress used as a crash mat next to Mr O’Hara’s bed. This resulted in a smouldering fire which created significant amounts of smoke. Mr O’Hara died from inhaling fire fumes and burns. The fire was only detected when a smoke alarm situated in the hallway of the flat detected smoke seeping through the living room door. Mr O’Hara’s death was recorded at 0420 hours that morning.

The inquest concluded with a short form conclusion of ‘Accident’.

Mr O’Hara was aged 63 at his death. He lived in a one bedroom flat on the ground floor of a two storey Independent Living Scheme in Frimley, Surrey. He was bedbound in his living room. He lived alone but carers came in four times a day. He misused alcohol and was known to smoke in bed. Concerns about fire risks from his smoking had been reported to both Surrey Fire and Rescue Service (SFRS), Surrey Adult Social Care (ASC) and the landlords. It was known that he could not self-rescue in the event of fire.

Mr O’Hara died in a fire on 7 February 2023 which resulted from a lit cigarette igniting debris on a mattress being used as a crash mat next to his bed. The resulting fire created a significant amount of smoke. The smoke detectors (one linked to a careline operator) and the intercom box were in the hallway. The door to the hallway from the living room was shut. As a result the fire was not detected until sufficient smoke had built up to seep through the top of the living room door into the hallway to then trigger the alarm. Once SFRS became aware that the alarm had activated they deployed quickly but Mr O’Hara died from the effects of the fire before they could reach him.

It is not known how long the fire had been burning before the smoke activated the alarm.

Evidence was given that the Safe and Well Visit in November 2022 was conducted by an inexperienced officer. The results of that visit did not seem to be subject to any scrutiny. SFRS do not appear to have in place a system of review or audit by line managers or more experienced staff of completed Safe and Well Visits, with the risk, as in this case, that errors or issues requiring action are not identified.

That SFRS reviews of individuals deemed high risk, are usually undertaken by the officer who conducted the initial Safe and Well Visit with the risk that opportunities for oversight and reassessment are missed.

Evidence was given that the visit to Mr O’Hara by ASC on 23 January 2023 should have resulted in a risk assessment. Although ASC has policy (some of which predated Mr O’Hara’s death) about when to conduct a risk assessment it does not appear to have in place a system of oversight to ensure that where appropriate, risk assessments follow a visit.