An inquest for a Belfast grandmother with dementia who died fin a fire at a residential home has blasted multiple organisations for missing repeated chances to prevent the tragedy.
Kathleen Fegan died in hospital aged 81 from severe burns on April 11, 2012, after the fire at the Owenvale Care Home on Belfast's Springfield Road.
It was found she had been smoking in her bedroom despite a policy meant to prevent her gaining unsupervised access to lighters or cigarettes.
Coroner Patrick McGurgan said Mrs Fegan had been discovered smoking in her bedroom on a number of previous occasions, including one alarming incident a month before her death in which staff found burnt underwear and trousers in her room.
Five years after her death the inquest finally concluded yesterday.
The coroner delivered a 16-page judgment in full in which he lambasted the former operators of Owenvale, the St John of God Association, as well as the Belfast Health Trust, regulatory body the RQIA and the Northern Ireland Fire and rescue Service for missing "red flag" warning signs.
He concluded that Mrs Fegan's death was both "preventable and forseeable".
Her granddaughters Nicci Reid and Terri Fegan said the final day of the inquest had been an equal mixture of relief and nerves, with the long drawn-out process being a trying time for the family.
"We're happy with the findings and we just hope now that they take heed and make the changes that need to be made and nobody goes through ever again what we've had to go through," said Ms Reid.
"It's good to finally get closure, it's been five long years."
Remembering her much loved grandmother, she added: "She meant the world to the family, she was the matriarch. If you had a problem you went to my granny and she sorted it out.
"She was a woman in a million and she didn't deserve what happened to her, nobody did."
Family solicitor Padraig O Muirigh added: "These findings today are very significant; it's an appalling list of failings. The breach of duty of care, red flags missed by the trust and the RQIA.
"So lessons need to be learned to point these agencies in the right direction."
Mrs Fegan was admitted to Owenvale in October 2011 after being diagnosed with dementia.
The manager at the time, Brother Michael Newman, was described by the coroner as "well intentioned" but "out of his depth" to effectively run the home.
His successor Cormac Coyle was appointed in February 2012.
Mr McGurgan acknowledged he made a sincere effort to address the problems but was also managing two other struggling St John of God facilities in Belfast, which the coroner described as "an impossible task".
He added: "This situation should not have been proposed by St John of God nor tolerated by the RQIA or by the trust...I find that it is completely appropriate that the St John of God exited the care sector in Northern Ireland."
The smoking policy at Owenvale required patients with dementia to request cigarettes to be smoked under supervision.
Mr McGurgan said this was "lamentable", as other residents were freely able to buy their own cigarettes.
Mr McGurgan said the Belfast Trust failed to properly assess Mrs Fegan's suitability as a resident for Owenvale.
Furthermore, neither Mrs Fegan or her family were present at two subsequent trust care management reviews.
The coroner said this "unacceptable situation" denied the family an opportunity to make an informed decision about Mrs Fegan's care.
The RQIA was criticised for failing to adequately assess the risk of fire from smoking or considering evidence for an urgent closure.
The Fire Service had issued a "broadly compliant" letter following an audit at Owenvale. The coroner said it had not properly assessed the issue of smoking in bedrooms and the assessment led to some "complacency" from St John of God, the trust and RQIA.