Belfast Trust admits failings in no-smoking policy after Kathleen Fegan's care home death
Belfast Health Trust has admitted it missed opportunities to spot major flaws in a care home's smoking policy in the weeks leading up to the death of an 81-year-old resident who perished in a fire after lighting up in her bedroom.
Kathleen Fegan suffered severe burns when a blaze broke out at Owenvale Court in west Belfast on April 11, 2012. The grandmother died from her injuries at the Royal Victoria Hospital, Belfast days later.
Kathleen, who suffered from dementia, had been smoking in her bedroom despite a policy that prevented her from having unsupervised access to lighters and cigarettes.
On the third day of the inquest, Belfast Coroner's Court heard how the "reddest of red flags were being waved" after a temporary care home manager contacted Belfast Health and Social Care Trust (BHSCT) asking for help because he was struggling to enforce the smoking policy.
A litany of mistakes in the lead up to the grandmother's death were highlighted during yesterday's proceedings, including the trust's failure to consider that she was a smoker with dementia when she was admitted to the care home in October 2011.
Marie Heaney, a senior official for the trust, said in her evidence that it appeared the care home provided safeguards that were "robust enough" at that time.
"The smoking risk was not taken seriously or addressed as it should be", she said. "We made a naive assumption about her smoking."
The court heard how in 2012 she was found twice smoking in her bedroom, she had burnt her underwear, there were burn marks on the carpet in her room and she was allowed to carry lighters and cigarettes.
Thomas Fitzpatrick, a barrister for the Regulation and Quality Improvement Authority (RQIA) stated that at no stage did the trust express any concerns until March 2012 about her having dementia or smoking.
During questioning, Ms Heaney said that the trust has since reviewed how it deals with patient reviews. Coroner Patrick McGurgan said: "It's a shame someone has to die before that is triggered. There was no proper cognisance that she had dementia. She burned herself twice before admission and that's not taken into account."
Ms Heaney replied: "We relied on the RQIA and the care homes. They were not disclosing difficulties that they were having."
In February 2012, Cormac Coyle, who was manager of Owenvale at the time, emailed the trust about the challenges of enforcing the smoking policy, particularly with people with dementia.
Mr Fitzpatrick said: "The reddest of red flags was being waved. This was a clear indication in February 2012 that the trust is entirely on notice in relation to the risks and being informed that this has to stop.
"He's saying, 'How do I stop it for people with dementia?'."
The inquest also heard a trust staff member checked the home daily after it emerged in January 2012 that it was struggling to address a number of issues raised by RQIA. Mr McGurgan said despite the visits, no notes were made about ongoing problems with the smoking policy.
"Smoking was particularly far down the hierarchy of issues despite it being raised by the manager", he added. At hearing.