Safeguarding Adults Review: Liam


Liam was a 47-year-old man who was described by his children as ‘an amazing support system’ and a loving dad. He was intelligent, motivated and fought for what he believed in. He was physically disabled and reliant on a substantial package of care for many aspects of daily living. Liam resided in rented accommodation and was understood to have capacity around his decision to smoke. It is understood the carers ‘usual practice’ was to leave a lit tea-light candle by his bed to enable him to light cigarettes after they left. The risk that this practice posed was not identified by carers or other professionals. 

Sadly, Liam died following a fire in his home in August 2021. The fire was believed to have been caused by a cigarette. Liam’s neighbour alerted services about the fire. 

Safeguarding Adults Review

This case met the threshold to become a Safeguarding Adults Review (SAR) as an adult with care and support needs died and there were concerns regarding the way agencies worked together to reduce the risk of harm to him. The SAR recommended that there may need to be a change in the law to allow fire brigades to apply for a fire safety prevention order when adults have mental capacity but refuse fire prevention support when the fire risks are high. 

Learning Points

  • Fire Safety in the Home training

Liam was supported in his choice of continuing to smoke at his bedside independently, but staff failed to identify the risks this posed to him and others. Had staff highlighted these as risks? Was he made aware of any risks?

Is Fire Safety in the Home training included in the training provided by your organisation? 

Are all staff including home care support aware of how to identify fire related risks and escalate them appropriately?


  • Risks relating to smoking

Liam was a known smoker and carers were well aware of his smoking habits. His Telecare was not linked to his smoke alarm.

Are staff recording smoking as a risk in reviews for people with high risk and/or mobility issues? 

Are staff considering options for mitigating fire risks e.g. offering smoking cessation support, fire retardant bedding, mist sprinkler system?

Is the smoke alarm linked to the Telecare system. Is this being tested regularly?

Where someone is at risk of fire, has a Person-Centered Fire Risk Assessment (PCFRA) been prompted and completed?


  • Working together

Multi-agency communication is key to keeping people safe. This is particularly important with fire risks. 

Are staff aware that an MDT review can be called without service user consent if there is high risk of injury or death to the person or others? London Fire Brigade should be involved in these meetings. 

Are staff aware of the Creative Solutions panel where high risk cases can be escalated for discussion in order to help mitigate risks? 


  • Refusal of care

Liam often refused care or ended care shifts early. He also refused a Home Fire Safety Visit (HFSV).  The refusal of care and shortened shifts were not reported to Adult Social Care (ASC) which meant risk assessments were not based on accurate information.

Are staff recording any refusal of care episodes in the care notes? 

Do staff know how/who to escalate this e.g. ASC, commissioning? 

Do staff know who to report HFSV refusal to?
Are staff regularly and routinely reviewing the risk assessment processes and care plans? 



If you are worried about someone who may be at risk of abuse or harm please contact the Access and Advice Team on 020 7527 2299 or complete the online safeguarding concern form