A raft of new safety measures has been introduced after a wheelchair-bound great-grandfather is believed to have died after smoking a cigarette and catching fire at a Bupa care home, an inquest heard.
There are no witnesses concerning what happened to Cedric Skyers, 69, in the garden of the Bupa-run Manley Court care home in New Cross, south-east London in March 2016.
Mr Skyers could not use his left-hand side after a suffering a stroke and had limited mobility, the inquest into his death at Southwark Crown Court heard.
His son David Skyers, 38, wants answers about various matters including his care plan supervision, his burns and whether a risk assessment was done.
Coroner Dr Andrew Harris told him at the start of his father's inquest: "These are all matters which I hope this evidence might provide some answers to."
The coroner later noted that "one of the benefits of this terrible tragedy is that there is better equipment and better awareness" on the part of Bupa of how to manage fires.
Nurse Odion Upasen Imieh, who carried out cardio pulmonary resuscitation on Mr Skyers, repeatedly broke down as she remembered him as a "funny" and "lively" man.
Pointing out the changes which have been imposed since his death, she told the court: "I always check residents' clothing to make sure there is no cigarette burns on their clothing.
"I ask the staff to report anything found to me.
"I always make sure they (the residents) wear aprons that are provided by the home - they are fire retardant.
"I make sure the garden is safe and there is no litter and the fire bucket is in place as well."
Ms Imieh, who had carried out a risk assessment of Mr Skyers, said the forms now used for this are more comprehensive.
Every question has to be answered and it has to be signed off by a manager, she said.
The coroner asked about the risk of medication and she said it is now included on the form.
She also said paraffin-based creams are no longer used. Under questioning from the coroner, she accepted there was intermittent supervision, stating: "We do now from time to time ... carers go out in the garden to pop their head in to make sure that the residents are safe."
Jamaican-born Mr Skyers was a retired labourer who had four children, three grandchildren and a great-grandchild.
He was a poetry lover who was still mentally capable and able to speak, according to his son David.
He told the inquest that his father "certainly had the capacity to light a cigarette" despite the pain he felt in his arm and leg.
Both staff and residents went into the garden to smoke and they had a shed they could use, the court was told.
Ms Imieh said she had received the mandatory fire training where she learned about evacuation.
She said she could not remember whether putting out fires was in the training.
The coroner added: "So what you did on the (assessment) form was just to the best of your knowledge and using your common sense."
Ms Imieh said that a risk assessment was done for all smokers.
Bupa fire safety adviser Julian Cable added there are now also pendant alarms for residents to make contact with the nurses if they are in distress.
He said "people are much more aware" of what would be needed to deal with fire.
The hearing was adjourned until Tuesday at 9.30am.
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