A family has raised questions at the inquest of an 81-year-old care home resident who died in a fire after smoking in her bedroom - even though staff knew she had to be supervised.
Kathleen Fegan was a resident of the Owenvale residential care home on the Springfield Road in west Belfast when she was critically injured in the blaze and died in hospital on April 11, 2012.
On Monday, her inquest heard evidence that smoking rules for patients with dementia at Owenvale were not being properly enforced and Mrs Fegan had been able to bring a lighter and cigarettes to her room.
Yesterday, Leona Askin, a solicitor representing Mrs Fegan's family, said there were multiple "red flag" warnings leading up to the grandmother's death.
The smoking policy stated that Mrs Fegan should only have been given individual cigarettes by staff, and supervised while smoking them in a designated room.
In 2012 she was twice found smoking in her bedroom, and on March 15 that year staff discovered she had burnt her underwear and trousers. None of the incidents were reported to the Belfast Health Trust or the regulatory body, RQIA.
"This is a month before her death," said Ms Askin, addressing Cormac Coyle, who was manager of Owenvale at the time.
"This would have been a red flag warning and you should have taken immediate action," she added.
Mr Coyle stated that a number of steps had been taken, such as increasing staffing levels and installing voice-activated smoke alarms in residents' bedrooms.
The court also heard how Mr Coyle was managing two other struggling facilities in Belfast operated by the care provider, St John of God.
Coroner Patrick McGurgan acknowledged the difficult position Mr Coyle was in at the time, but said the smoking policy had no chance of working.
Further evidence was heard about an email from a resident at Owenvale who claimed that, just before the fire, Mrs Fegan entered the smoking area and asked to borrow a lighter which she put in her pocket.
The coroner commented: "That sets out the stark reality of that smoking policy. It seems with the best will in the world it was going to be impossible to police this."
Marie Heaney, a senior official for the Belfast Health and Social Care Trust, gave further evidence yesterday in the case.
"This is the first time in my 35 year (career) of an older person dying from fire in a care home. What we didn't realise was how deteriorated the management at Owenvale was at the time," she said.