A disabled care home resident died in a fire after she became trapped by a lock fitted to the inside of her door and staff failed to follow fire safety procedures, a coroner has found.Ashlie Timms, 46, died in the blaze at Connington Court in Chingford, east London, in 2018.
An inquest heard Ms Timms lived with physical disabilities, a moderate learning disability, and a borderline personality disorder.
She was found dead in the hallway of her supported living flat after a fire in the early hours of the morning, due to the ignition of fabric materials by a fan heater.Fire detectors in Ashlie's room triggered a fire alarm system that alerted staff between 1.30am and 2am.
However, this alerted them to the wrong location and therefore staff could not find a fire after an initial search and the alarm was reset.
Staff did not evacuate the building or call emergency services, the inquest heard, which concluded on 12 April, 2022Staff later inspected Ms Timms' flat and discovered a well-established fire. Thick smoke prevented them from entering and saving her.
A call was made to 999 at 2.13am - over an hour later.
There were even more delays of between 43 and 28 minutes in calling 999, coroner Graeme Irvine wrote in a Prevention of Future Deaths Report published last week.The door to Ms Timms' flat was fitted with a combination lock on the inside, meaning she had to enter a code to exit, against the advice of the company hired to install it.
The presence of a key-pad on an exit was described as both unusual and dangerous, the coroner added.While the fire alarm going off should have caused the door to automatically open, firefighters found that two other locks in the building had malfunctioned on the night of the fire.
When questioned about the lock at the inquest, the home’s manager at the time Sonia Sandhu broke down, telling the jury: “I did not think she had issues using the lock.
"We had done multiple trials… Ashlie responded well and had shown she was good with the keypad.”
The jury also heard from Ms Timms' social worker at Hertfordshire Council, Peter McVicar, that she complained about forgetting the code only four months before the fire.Pointing to evidence presented at the inquest, the coroner added: "Multiple staff members who gave evidence remained unable to describe the proper action to take in the event of a fire alarm...fire safety procedures, policies and risk assessments in place at the unit were found to be unfit for purpose."
A London Fire Brigade fire safety audit of the premises on October 3 2017 - six months before Ashlie's tragic death - found that staff training and fire risk assessments were suitable and sufficient.
The audit was determined to have been flawed.
The coroner called on London Fire Brigade to update their processes to prevent future deaths.(BPM Media).