Raymond BRATTLEY · Prevention of Future Deaths report

On 16th January 2024, I commenced an investigation into the death of Raymond Brattley, aged 71 years. The investigation concluded at the end of the inquest on 13th June 2024. The conclusion of the inquest was: ACCIDENT

These are set out in my summary and findings of facts which are attached.

Raymond BRATTLEY was a heavy cigarette smoker, who on a number of previous occasions placed partly extinguished cigarette ends into a wastepaper bin in his flat, which subsequently caught fire, but these were successfully extinguished. On 8th January 2024, a fire resulted in his flat from careless smoking, which engulfed Mr Brattley resulting in him developing widespread full thickness burns to his entire body from which he rapidly died at the scene.

It was known to the staff at Portland Mews that this gentleman was a heavy smoker and that on a number of previous occasions, he set fire to waste paper bins in his flat as well as burning himself, carpets and soft furnishings due to careless smoking. On all previous occasions, the fires were contained or extinguished. Appropriate action was taken by the staff in respect of this issue. However, in the most general of terms, evidence was heard from a fire investigator, that if issues of this nature arise in other organisations or care settings, they should be brought to the attention of the Fire Service, who would freely provide advice about ways in which to mitigate the ongoing and foreseeable risk of cigarette related fires occurring in other vulnerable individuals. Such measures might include the provision of metal wastepaper bins and the use of fire-retardant materials. It is recognised that in similar institutions, tenants are permitted to smoke on such premises, but there is a tension between allowing smoking on the premises and risk of fires occurring, particularly in vulnerable individuals who may have similar mobility problems to Mr Brattley.