An elderly couple died in a horrifying house fire despite pressing a panic button after a call operator failed to hear a smoke alarm going off in the background.
Caroline and Bernard Cleall, both in their seventies, perished in the blaze in Addiscombe, south London in January 2022 when an emergency care responder was sent instead of the fire brigade.
Firefighters only rushed to the blaze once the responders reported it but they arrived 'too late' to save the couple.
Croydon Adult Social Care services arranged Mrs Cleall's care package in September 2021 with the help of an NHS organisation called Living Independently For Everyone (LIFE) Services.
An alarm call button on a pendant was provided for her home on Windermere Road by the Careline service, arranged by the London Borough of Croydon.
But as she was given a 'basic telecare package', Mrs Cleall only had access to a call operator whereas a more expensive package would have included an 'automatic smoke detector facility'.
Ivor Collett, Assistant Coroner for South London, concluded that the couple's deaths were accidental but raised concerns over the alarm button they were given.
He said: 'On the day of the deaths, Mrs Cleall operated the pendant button but was unable to communicate meaningfully with the call operator as she was stuck in the sitting room of the house where the fire had taken hold (away from the main communication device), and her husband was incapacitated by smoke / fumes.
'A smoke alarm was sounding in the sitting room but it was not heard by the call operator.
'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.
'The firm view of the fire service is that telecare services should by default be recommended to include the enhanced package option.
'This includes a smoke detector which, when triggered, sends an urgent signal to the call operator without the need for the client to operate the pendant button.
'That automated call would result in the fire brigade being notified of an emergency immediately.'
The coroner expressed concerns that Croydon Adult Social Care were unable to access the records of Mrs Cleall's assessment carried out at Croydon University Hospital in 2021 because it was held on an NHS system which it could not access.
Mr Collett said a discussion should have been had with Mrs Cleall about the level of package which would be appropriate for her and a risk assessment should have been carried out.
If she declined a more expensive package against the advice she was given, the decision should have been documented, but there was no evidence of the content of any assessment, advice or discussion had with the elderly woman.
Croydon Adult Social Care reviewed Mrs Cleall's situation four to six weeks after she was discharged.
The coroner found that the body did not have access to records of any assessment or discussion which had taken place with her.
'This would mean that the review was missing vital information which might have had a bearing on whether the telecare package should have been revised to include the enhanced service with an automatic smoke detector facility,' Mr Collett said.
'In summary, I am concerned that the inability of LB [London Borough of] Croydon Adult Social Care professionals to access records of an earlier assessment undertaken (and advice given) by their colleagues, together with the NHS LIFE team, deprives LB Croydon Adult Social Care of the ability to review the client's needs properly (with the necessary information) following discharge into the community.'
The coroner's prevention of future deaths report has been sent to the London Borough of Croydon, which must respond within 56 days.
