Elderly couple died in house fire after 999 operator did not hear smoke alarm
An elderly couple died in a house fire after the smoke alarm was not heard by the operator during a 999 call, an inquest heard.
Bernard and Caroline Cleall, both in their 70s, perished in the blaze at the detached property in Addiscombe, near Croydon, south London, on the evening of Jan 5 2022.
Mrs Cleall, who suffered from health issues including limited mobility, had been discharged from hospital months earlier with an alarm call button to be worn on a pendant all day.
On the day of their deaths, Mrs Cleall pressed the alarm but was not able to communicate sufficiently as she was stuck in the room where the fire took hold and Mr Cleall was already incapacitated by the smoke.
A smoke alarm was sounding in the same room but this was not heard by the call operator.
Ivor Collett, the assistant coroner, said: 'The operator caused Careline responders to attend, but the fire brigade were called only once the responders arrived and discovered the fire.
'By that time it was too late to save the two occupants of the house.'
At an inquest in April, their cause of death was given as 'inhalation of smoke'.
Four fire engines and 25 firefighters were called to the cul-de-sac at 8.08pm and the blaze was under control by 8.59pm.
Mr Collett raised concerns that Mrs Cleall was not given the enhanced alarm package, which includes a smoke detector.
When triggered, the smoke alarm would have sent an urgent signal to the call operator without the need for the pendant button to be pressed.
That automatic feature would have resulted in the London Fire Brigade being notified of an emergency immediately, the coroner said.
Mr Collett issued a Prevention of Future Death report on May 9 raising further concerns about the assessment of which alarm package patients should be given.
There was no evidence in this case of the content of any assessment, discussion or advice as to the appropriate level of alarm package for Mrs Cleall, he said.
He also raised concerns that Croydon social care services was not able to access the record of assessments carried out at Croydon Hospital, depriving it of the ability to review patients' needs properly following discharge into the community.
After their deaths, one neighbour said: 'They are a kind old couple ... The woman could barely walk. I know the son visits sometimes, but I don't think he was in.'
Another neighbour said: 'They seemed like a sweet couple who always liked pottering around in their garden with their dogs. It looks like they lived there for a long time.'
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