A care provider has been dropped by Islington Council after a coroner returned a finding of "unlawful killing" over the death of a vulnerable man with multiple sclerosis in a blaze.
Paul Lewis, who was largely immobile, was alone at his Stroud Green home when his bedding caught fire in August 2021.
A neighbour heard him shouting for help and alerted emergency services, but the 47-year-old died of smoke inhalation before he could be reached.
At an inquest held at St Pancras Coroner’s Court, a range of failings were found to have contributed to Mr Lewis’ death.
Coroner Mary Hassell said that on the evening of August 26, 2021, Mr Lewis instructed his carer to leave his home in Hanley Gardens rather than staying overnight as planned.
It was determined that Mr Lewis had been left with a burning tealight on top of two cardboard shoe boxes stacked on top of one another on his bed.
This was so that he could make use of the tealight and a paper taper to light his cigarettes. Ms Hassell said that this was “manifestly, completely unsafe”.
After the fire, it was found that Mr Lewis did not have his pendant alarm around his neck when he died.
Ms Hassell determined that when his carer left for the night, they did so without placing the alarm around Mr Lewis’ neck. She added that this was “truly, exceptionally bad”.
No evidence was found that a full fire risk assessment had been carried out by Mr Lewis' care provider Snowball, nor that there was an effective evacuation plan in place for Mr Lewis.
Ms Hassell said: “The home had candles, Mr Lewis was a smoker, and of all four limbs he only had the extremely limited use of one arm. He had a high fire risk.”
She added that even if the fire had been started by Mr Lewis dropping a paper taper, and not the tealight, the failure to place his pendant alarm around his neck was a “grossly negligent breach of duty”.
Ms Hassell said that if the pendant alarm had been around Mr Lewis' neck, it is likely firefighters would have arrived in time to save him.
The Coroner ultimately returned a verdict of “unlawful killing” on November 16 last year.
Following the inquest, Islington Council confirmed it had stopped working with Snowball, citing a "significant loss of trust" in the provider.
A spokesperson added: “The safety of our residents and the quality of care they receive is a top priority.
"We have told our residents who currently have their care provided by Snowball that we will stop working with this provider, and we will work with those residents to make alternative arrangements for their care.
“In the meantime, we will continue to closely monitor Snowball to ensure it meets the highest standards of care, alongside the Care Quality Commission.”
Snowball has been asked if it would like to comment on the council's decision.
Following the verdict, the Care Quality Commission and the Metropolitan Police both said that they would review the evidence to determine if new investigations were needed.
Last November, a spokesperson for Snowball said: “First, we want to say that our thoughts and sympathies are with the family and friends of Paul Lewis at this time.
“The circumstances surrounding his death were horrific and extremely upsetting for everyone involved and all those who knew him.
They added: “At the time and in line with proper process, we reported the circumstances of his death to the local authority adult safeguarding unit and to our regulatory body, the Quality Care Commission (CQC).
“We have co-operated openly, fully and with complete transparency with all external investigations into Paul’s death and with the coroner’s inquest.
“We have already reviewed our policies and procedures, staff training and recruitment as well as the company’s health and safety and risk assessment procedures.
“We will reflect on all the coroner’s findings and on all her comments, but we are pleased that the coroner recognises that many positive changes have already been made by Snowball in improving processes since Paul’s death.”
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