Paul Lewis died at his home at Hanley Gardens in 2021

A CORONER has returned a finding of “unlawful killing by way of gross negligence manslaughter” after an inquest into the death of an MS sufferer trapped in his bed as a fire spread through it.

An inquest heard that a carer from Islington’s private contractors left Paul Lewis, who was completely immobile, with a lit candle on top of shoeboxes on his bed. His Telecare pendant, which he could have used to call for help, was out of reach.

He died at his home in Hanley Gardens, Stroud Green, in August 2021 but the inquest was adjourned several times before St Pancras coroner Mary Hassell was able to reach her final verdict yesterday (Thursday).

Mr Lewis, 46, died after his bed caught fire, caused by lit candles or paper tapers, which the inquest was told had been left by carers to aid him in lighting his cigarettes. It was a case which fire investigators said had left them “astonished”.

His carer had left him alone around an hour before the fire started, and had failed to notify his care agency, Snowball Care.

Speaking after the ruling, his ex-partner Emma Hall said: “I need to take some time to think about it, but I am going to keep going with this. I’m not going to go away. I want to look at how I can prevent it from happening to somebody else.”

Standing beside one of Mr Lewis’s sons outside the court, she added: “We’re relieved. Emotional, obviously. But I feel that it’s part of the way for justice for Paul.”

Emma Hall and her and Mr Lewis’s son, Kai Hall

Earlier, Ms Hassell said Snowball’s manager, Sayeda Ahmed, had shown “breathtaking complacency” over her understanding of fire safety standards, after she admitted over two days of evidence that she had no record of training staff in fire safety in Mr Lewis’s care and had not conducted an adequate fire risk assessment of his home. There was no fire evacuation plan in place and carers did not know whether the smoke alarms in his home worked.

“Ms Ahmed’s initial unprompted evidence at inquest was that there was not actually any fire risk: that everyone who smokes does so in their own home and that Paul was competent about his smoking,” Ms Hassell said.

“That betrays to me a breathtaking complacency about this person’s fire risk. The home had candles. Paul was a smoker and of all four limbs, he only had the extremely limited use of one arm. He had a high fire risk.”

At the inquest, Snowball staff said the original statements made to fire investigators in the immediate aftermath of Mr Lewis’s death were untrue. Some staff later claimed the candles were scented and had never been used to assist him with his smoking.

This was something Ms Hassell rejected, calling their evidence “conflicting and confusing” and branding this version of events “not credible”.

She said she found their practices with Mr Lewis “manifestly completely unsafe”, adding: “Fire investigator Steven Elliot gave evidence that Snowball manager Sayeda Ahmed told him at the scene that she did not deem placing a lit tea light on top of a cardboard box next to a man with multiple sclerosis a fire risk.

St Pancras Coroner Mary Hassell

“Her evidence at inquest was that this was not true: that she had never said this. However, Mr Elliot had also made a contemporaneous note. He also had no reason to lie, and I found him to be credible and impartial. I accept his evidence.”

At times sounding emotional herself as she delivered the verdict following an inquest which heard shocking details of Mr Lewis’s death, she said: “For all the reasons I have indicated, the leaving of a man as physically compromised as Paul Lewis with a burning tea light on top of a cardboard box, on top of another cardboard box, on top of his bed, I do find to be truly exceptionally bad and so reprehensible as to amount to gross negligence.”

She said that regardless of whether the fire was caused by the candle or the paper taper – which could have been legally regarded as an “intervening act” on Mr Lewis’s part – she said she reached a conclusion of “unlawful killing” as carers had also failed to place the pendant around Mr Lewis’s neck.

Had they placed the Telecare pendant within reach, he could have alerted emergency services, she suggested, adding: “I find it likely in this scenario that the London Fire Brigade would have been in time to save him.”

Speaking in court last week, Ms Hall described how the family were haunted by his death.

“Can you imagine the panic?” she said. “He was completely engulfed in flames. He couldn’t move. We were told that he would have been alive for three minutes. In some ways, three minutes is such a long time. If you count it out it’s such a long time.”

Response from Snowball Care Limited

FULL STATEMENT RELEASED TO THE TRIBUNE LAST NIGHT AFTER THE INQUEST: First, we want to say that our thoughts and sympathies are with the family and friends of Paul Lewis at this time.

The circumstances surrounding his death were horrific and extremely upsetting for everyone involved and all those who knew him.

Investigations into Paul’s death have been carried out by the fire brigade and the police. In addition, at the time and in line with proper process, we reported the circumstances of his death to the local authority adult safeguarding unit and to our regulatory body, the Quality Care Commission (CQC).

We have cooperated openly, fully and with complete transparency with all external investigations into Paul’s death and with the coroner’s inquest. We have already reviewed our policies and procedures, staff training and recruitment as well as the company’s health and safety and risk assessment procedures.

We will reflect on all the coroner’s findings and on all her comments, but we are pleased that the coroner recognises that many positive changes have already been made by Snowball in improving processes since Paul’s death.

In the meantime, Snowball Care UK is determined to provide the best possible care and service levels and we will be happy to talk to any service user, family member or carer who has any concerns about any media coverage or public comment made in respect of this case.

Response from Islington Council

An Islington Council spokesperson said: “We offer our sincere and heartfelt condolences to the family and friends of Paul Lewis for their tragic loss, and we are very sorry that more could have been done to prevent his death.

“We will very carefully consider all of today’s findings and will take all appropriate actions.

“The safety of our residents and the quality of care they receive is a top priority.

“The coroner’s findings are clear that concerns remain about the way care was provided to Mr Lewis.

“Snowball’s current rating from the Care Quality Commission is ‘Good’.

“The council has been working with this agency over the course of two years to improve its practice. We will continue to closely monitor Snowball to ensure it meets the highest standards of care, alongside the Care Quality Commission.

“We will be working with the Islington residents still under the care of Snowball to decide on next steps.

“We’ve already taken a number of key actions, and are strongly committed to learning further lessons, alongside the other partner organisations who are involved.”