A 63-year-old bedridden man was killed in a house fire after smoking in bed, shortly after an "inexperienced" officer carried out an "unscrutinised" safety visit of his independent living flat.

In February 2023, Kevin O'Hara died from smoke inhalation and burns after falling asleep while smoking, an inquest found.

Mr O'Hara had been visited in his Frimley home by Surrey Fire and Rescue on 17 November 2022, for a 'safe and well visit' which failed to identify the correct position for the smoke detector or his careline monitor.

A later visit by Surrey's Adult Social Care team, on 23 January 2023, also failed to include a risk assessment – despite concerns for his health and the dangers of smoking in bed. 

This was all the more urgent as it was known that would not be able to get himself out of the house independently in the event of a fire. 

According to the Prevention of Death report, Mr O'Hara died in a fire that started from a lit cigarette "igniting debris" on a crash mat next to his bed.

His smoke detectors and the intercom box, however, were in the hallway and the door shut.

The alarm was only triggered when enough smoke had built up to seep through the top of the living room door.

Mr O'Hara died before emergency teams could reach him.

Both Surrey Fire and Rescue, as well as Surrey Adult Social Care, say they have since undertaken work to mitigate the risks of a recurrence, including serious incident reports, increased training and greater coordination across teams. They say they have also adopted an improved 'person at risk' referral system to better identify fire dangers to individuals.

The coroner, Susan Ridge, however said more needs to be done to ensure a review system is in place to give more oversight to experienced staff.

The report reads: "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.

"Surrey Fire and Rescue does 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."

Tim Oliver, Leader of Surrey County Council: "We would like to express our deepest condolences to Mr O'Hara's family and anyone else affected by his tragic death.

"We recognise the importance of learning from serious incidents and carried out a review of what happened in this case which led to our fire and rescue service and adult social care service working together to introduce a new process for identifying people at risk.

"Surrey Fire and Rescue Service has also enhanced its training for officers involved in Safe and Well Visits and is in the process of developing a quality assurance system to identify and address potential risks more effectively.

"We will continue to embed an understanding of prevention activity across the service.

"Within adult social care, we have taken steps to strengthen management oversight over risk assessments and have brought in further training for staff.

"While we have taken a number of actions in the months since this case, we are carefully considering the coroner's findings and are committed to doing all we can to improve the way we support vulnerable people and manage any fire risks they face."