Warren, Michael

Contributing factors

• Patient smoking alone in unsupervised courtyard area without call button
• Lack of active safety assessment of smoking risks despite known diminished physical capability
• Staff assumption that patient managing smoking meant it was safe
• Patient unable to call for help due to aphonia
• Patient unable to extinguish fire or remove flaming clothing due to weakness and immobility
• Difficulty operating fire hose due to equipment unfamiliar to staff member
• Inadequate hands-on fire safety training
• Flammable clothing (cotton terry towelling dressing gown and hospital pyjamas)
• MND staff awareness gap - nursing staff unfamiliar with disease progression and functional limitations
• Patient used matches instead of lighter but staff were unaware of this change

Coroner's recommendations

1. Queensland Health must commence all smoking policies from a physical safety assessment of fire hazards and burn risks to patients and others
2. Documentation should be amended to prompt staff consideration of patients' capacity to safely smoke and to record appropriate risk assessments
3. Continuous assessment of a patient's capacity to safely smoke is required throughout admission
4. Queensland Health should consider management of situations where patients may choose to smoke in the grounds or peripheries of facilities
5. Queensland Health should consider whether smoking policies should be consistent across the state or retain district-level scope
6. Regular hands-on training of all staff who may be called upon to extinguish fires or evacuate patients should be prioritised with sufficient resources allocated
7. An awareness-raising initiative concerning Motor Neurone Disease should be implemented to help nursing staff appreciate the particular difficulties and progressive nature of the disease
8. Queensland Health should ensure supervision of patients during smoking if designated smoking areas are permitted