Inquest finds St Leonards hospice patients were unlawfully killed in fire

Thursday 21 November 2019

Patrick Roche of Garden Court represented the family of Jill Moon, instructed by Shakiratu Sanusi of Birnberg Peirce and Partners. Patrick and Shakiratu are members of the INQUEST Lawyers Group.

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At an inquest in Hastings yesterday Senior Coroner Alan Craze concluded that three patients who died after a fire at a hospice on 11 July 2015 were unlawfully killed.

Jill Moon, Pearl Spencer and David Denness, were all suffering from cancer but Forensic Pathologist Dr Fegan-Earl told the inquest that the fire at St Michael's Hospice in St Leonards, East Sussex had hastened their deaths. Dr Fegan-Earl stated that none of the deceased would have died when they did but for the fire.

The Coroner concluded that another patient had started the fire deliberately or grossly negligently. He died before he could stand trial for arson.

St Michael’s Hospice pleaded guilty at Lewes Crown Court in March 2018 to two serious breaches of fire regulations and was fined £250,000. The Hospice appealed against this sentence but the appeal was rejected by the Court of Appeal.

Her Honour Judge Henson QC stated that the Hospice’s culpability was high. Its failures in basic failure safety, which the Judge described as “obvious and avoidable”, included locked exits which staff could not open, no equipment to take patients down stairs, no training in evacuation procedures or evacuation drills. In addition, the fire was able to spread rapidly because there were holes in the ceiling and doors had been wedged open in breach of fire safety regulations. The Judge stated that these failures could have been rectified quite simply and at little cost.

Nursing staff tried to evacuate Jill Moon and David Denness but were forced to leave them in a smoke filled room for 10 minutes when they were unable to get their beds out of the building through the external doors. Fire fighters broke down the doors to get them out. Jill Moon and David Denness both suffered smoke inhalation as a result of the fire Pearl Spencer’s bed was on the second floor. She was only evacuated when the fire fighters arrived.

At a pre inquest hearing in November 2018 the Coroner accepted arguments put forward by the Hospice and Fire Service that it was unnecessary for him to hear any evidence about fire safety failures because of the previous criminal proceedings, despite representations on behalf of the Moon family that the Crown Court had not called any witnesses and that the families had not had any opportunity to participate in the criminal proceedings.

During the inquests the court heard evidence that two days before the fire, the patient who started it had made three hoax 999 calls from the Hospice reporting a fire in Battle and stating that he had been attacked. Police attended the hospice on that day and were told that he had smashed the windscreens of a number of cars. The court was also told that hospice staff had warned him about smoking next to flammable oxygen canisters. Detective Constable Green told the court that the Hospice had been told about the hoax calls but that no action had been taken. When questioned by Patrick Roche, the barrister for the Moon family, Dr Chowdhury, the medical director of the Hospice, stated that if she had been informed of the hoax calls, the patient would have been discharged from the clinic immediately.

After the inquests concluded, the Moon family issued the following statement:

“We have waited 4 ½ years for this Inquest since Jill’s death. We were hoping that we would finally be able to hear and understand everything that happened to her during and after the fire. We did get some answers. 

"The hospice pleaded guilty to serious breaches of fire safety regulations and were fined £250,000 following prosecution by the Fire Service last year. However those failures have never been aired publicly and it is disappointing that the Inquest itself couldn’t address these failures. 

"Though the hospice has now put safety measures in place, it is unacceptable that such a fire had to happen to prompt this remediation. What the fire did was to ruthlessly expose the existing deficiencies. 

"Further to this, we heard that despite several warning signs, there was no action taking to safeguard staff and patients against the potential threat of the individual who caused the fire.

"We know that the fire hastened Jill’s death, which was the result of Hospice’s gross structural and systemic failures and made her final hours agonising. We had expected her to be safe, free from harm and able to maintain her dignity at the Hospice.

"We fought long and hard, and at a great personal, emotional and financial cost to the family to get to this point.

"Both the hospice and fire service had lawyers to represent them. Families should also have public funding to be represented in these matters to assist them getting truth and accountability.

"We are grateful to the all of the individuals who were involved in the rescue of our mother, Jill Moon, who showed great bravery and dedication. “

The inquest was reported on by the media, including by the BBC.

Patrick Roche is a member of the Garden Court Chambers Inquests and Inquiries Team

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