William Thompson died of smoke inhalation in November 2014 when his bedding caught alight from a discarded cigarette. He lived in supported housing and while smoke alarms were installed in his hall and kitchen, there was no smoke detection system in his bedroom.

Coroner Hassell said Mr Thompson’s social workers “never addressed their minds to the question of whether there was a smoke detector in his room and, if not, whether that might be useful”, despite him being at high risk of fire due to his smoking, drinking and immobility.

Hassell added that this issue would “benefit from exploration” for high-risk service users.

A spokesperson for Hackney council said: “Our thoughts are still with Mr William Thompson’s family after his tragic death. Hackney council and London Fire Brigade had been doing a lot of work to support Mr Thompson and his family in relation to fire risk and we remain committed to ensuring that we learn lessons from this very sad incident.”

The case was referred to a safeguarding adults review, which resulted in the development of a self-neglect protocol and increased staff training on fire safety.

The council spokesperson added: “Fire alarms are just one tool used as a fire safety measure, with fire safety awareness and home checks also being used to ensure the safety of service users. In addition, the council often makes referrals to London Fire Brigade for fire alarm installation and check-up. Whoever is best placed to check smoke alarms should do so, and this will depend on each individual case, so it may be, for instance, a friend, family member, social worker, occupational therapist, or London Fire Brigade themselves.”

Source: Community Care