Case study: learning from a fatal fire in Wigan

Improving partnership links with Adult Social Care and independent care providers

Gaps in fire safety awareness in the care provider partnership were identified during post incident learning from a fatal fire in Wigan borough in 2023. The property was a sheltered housing bungalow, adapted for elderly people and those with mobility and other health conditions, provided by the local authority. Fixed point smoke alarms were fitted and operating in the property. The fire was caused by accidental ignition of clothing and bedding from a discarded cigarette.

The fire investigation found that the casualty had a full care package in place (carers visited five times a day), was bed-bound and unable to self-evacuate. It also highlighted that there was extensive evidence of carelessly discarded smoking material in the living room and bedroom.

The casualty was:

a heavy smoker and smoked in bed
lived with mobility issues and was unable to self-evacuate
receiving domiciliary home care

The casualty was eligible for a Home Fire Safety Assessment (HFSA) from GMFRS, but had not been referred, highlighting the importance of systematic consideration of fire safety for vulnerable people.

The GMFRS Prevention Manager for Wigan and Bolton met with the Wigan Safeguarding Adults Board, Adult Social Care and independent care providers to look at what could be done to reduce the risk of fire for adults in similar circumstances.

Scope of learning and action

Wigan Safeguarding Adults Board instigated a Brief Learning Review to identify any other agencies open to the casualty and any learning. As part of the ethical framework for safeguarding adults it was recommended that all front-line staff involved in the assessment or provision of care packages and their delivery attend the GMFRS Partnership Training to increase awareness of potential fire risk in homes and the GMFRS HFSA referral process.

The GMFRS Prevention Manager included the following recommendations in his Prevention Report for HM Coroner:

Any vulnerable person who needs a care assessment be considered for a referral to GMFRS for a HFSA
All partner agencies consider releasing frontline staff to attend one of the training offer options from GMFRS, particularly those involved in either home assessments or provision of home care
Links to the GMFRS partner information webpage be included within partner agency intranet or internet pages

Outcomes

Key benefits and outcomes include:

Improved awareness of fire risk in homes by frontline key workers across all agencies
Improved partnership working and increased referral rates to GMFRS for HFSA visits
All care assessments now include consideration of a referral to GMFRS, depending upon individual circumstances and risk
Adult Social Care and all care providers are aware of our referral process
The GMFRS training is now promoted in the Wigan Safeguarding Training catalogue
Over 300 frontline staff from Wigan, including social workers and carers, have attended GMFRS partner training sessions since the learning review and referral rates have increased significantly for HFSA visits
Partner websites now include links to GMFRS and the HFSA referral pathway

Summary

The learning from the fatal fire incident identified gaps in fire risk consideration across the Adult Social Care partnership in Wigan and Bolton. Action has been and continues to be taken to reduce these.

It is recommended that all partners engage and adopt the Seven Simple Steps approach to working together to reduce the risk of fire across Greater Manchester. In particular, it is recommended that agencies consider releasing frontline staff, particularly those involved in either assessing or delivering care in the home, to attend the training offered by GMFRS.