Transcript for Learning from SAR Alison - home fire safety

[Background music starts]

Lloyd Palmer, Borough Commander, London Fire Brigade: The Hammersmith & Fulham Safeguarding Adults Board recently concluded a review which focused on the involvement of partner agencies with a woman who we have called ‘Alison’.  

Alison was in her late fifties and lived with her civil partner. She had a long history of substance misuse and a number of long-term health issues. Alison was reliant on her partner, a wheelchair user, and carers to support her. Alison struggled to mobilise from her bed and she also smoked around twenty cigarettes a day.

There were a number of agencies who had regular contact with Alison, and her partner also had a package of care in place. Some agencies struggled to maintain engagement with Alison, who would often decline offers of support. A Safeguarding Adults Review was commissioned following Alison’s death in December 2021 as a result of a fire in her own home.

[Title card]: Recognising fire risk

Lloyd Palmer: The review has highlighted the importance of being able to properly recognise fire risk in the home.

There are a few simple things that you can look for when you are visiting someone’s home, including whether there are working smoke alarms in the home and whether there is a clear escape route.

Someone London Fire Brigade would consider high risk would include someone who is over-60 and living alone, a regular smoker, and living with reduced or limited mobility, so making it more difficult to escape in the event of a fire.

This could include people who spend a significant proportion of time in bed or in a chair due to their limited mobility or other health reasons, and in receipt of care whether informal or formal.

[Title card]: A good home fire safety risk assessment

Kenny Dickson, Director of Operations, Graceful Care: When we visit someone we work with in their home, we have a dedicated fire risk assessment that we carry out.

[Graphic on screen of risk factors for fire hazards]

We try to consider all possible fire hazards. We look out for certain warning signs, such as:

• burn marks on carpets or furnishing from smoking
• likelihood of leaving cooking unattended
• and use of electric blankets or portable heaters

We also think about how to mitigate risk from use of emollient creams, oxygen tanks or substance misuse, and consider the person’s ability to escape if there were to be a fire – this includes thinking about their capacity to respond.

Our risk assessment template will consider the person’s individual circumstances and any existing control measures, before making an assessment as to whether there is still outstanding risks requiring action. This includes whether we need to discuss the risks with our multi-agency colleagues.

[Title card]: How to make a referral to London Fire Brigade

Lloyd Palmer: The London Fire Brigade offers a service where we can visit you, or someone you care for or work with, to provide personalised advice about fire safety at home.

Depending on your personal circumstances, we might also suggest extra help and support from other organisations. This could be to discuss things like fire retardant bedding or linking a smoke alarm to your telecare system.

We would encourage everyone to make use of the online Home Fire Safety Checker.

You can do this to assess the risk in your own home, or even on someone else’s behalf, so professionals can use this tool for someone they are working with.

Everyone who completes the checker will get a personalised action plan and advice, and the checker will also indicate if there is higher risk of fire and we can arrange for a home fire safety visit to be carried out.

[Title card]: Multi-agency communication and referrals

Ceri Gordon, H&F Safeguarding Adults Board Manager: When we have identified that someone we work with is at risk, we need to take steps to mitigate this, particularly when, as in Alison’s case, they are refusing or disengaging from services.

Multi-agency communication is key for managing the risks for any case. We as professionals must ensure that we are being proactive in sharing what we know with relevant agencies. Different practitioners often receive different information. Sharing these perspectives allows us to see the full picture, and having an awareness of what other partners can provide to mitigate risks also helps us to plan and share the risk.

As a starting point, it would be best practice to bring together colleagues in a meeting to identify the key issues, asses the risk and create a joint action plan whilst identifying the lead agency that is best placed to oversee implementation of the plan. You may also consider at this stage whether you need to raise an adult safeguarding concern.

Where a case is particularly complex, multiple efforts have been made to reduce risk and where professionals feel stuck with what to do next, then it may be appropriate to refer to the Hammersmith & Fulham High Risk Panel which seeks to provide challenge, advice and support, and identify multi-agency solutions and action plans. More information about how to refer can be found on the Hammersmith & Fulham council’s website. The address is now on your screen.

Lloyd Palmer: The learning from the review into Alison’s death will help to make positive changes to the way we work and promote best practice. We all have a role to play and can make a huge difference. If you want to find out more about what happened to Alison or access more learning resources, please visit our website.

[End card]: Website URLs for London Fire Brigade and H&F Council are displayed followed by the logos for:

• Hammersmith & Fulham Safeguarding Adults Board
• Hammersmith & Fulham Council
• Hammersmith & Fulham Health and Care Partnership
• London Fire Brigade
• Metropolitan Police