APPENDIX A , item 24. PDF 4 MB - Greater Manchester Fire and ...

APPENDIX A
Learning from
Preventable and
Non-Preventable
Fatal Fire Incidents
2011-2012

CONTENTS
Contents…………………………………………………………………………………… 2
Foreword…………………………………………………………………………………... 3
Summary……………………………………………………………………………………4
Introduction…………………………………………………………………………………5
Who?...........................................................................................................................6
Total number of fire deaths………………………………………………………..6
Number of fire deaths by age and gender…………………………………….....7
When?.......................................................................................................................11
Number of deaths by month, season, day and time…………………………..11
Where?......................................................................................................................15
Number of deaths by borough…………………………………………………...19
Why?..........................................................................................................................25
Smoke detection…………………………………………………………………..25
Suicide……………………………………………………………………………..31
Conclusions……………………………………………………………………………….38
Recommendations………………………………………………………………………..39
2

FOREWORD
The purpose of Greater Manchester Fire and Rescue Service (GMFRS) is to protect
and improve the quality of life of the people in Greater Manchester.
Throughout the last five years we have studied in detail all data relating to fatal fires
that have occurred within Greater Manchester. The aim of this research was to
identify and determine trends, along with contributory factors, that may allow us to
understand why members of our communities are still losing their lives in accidental
fires within the home, or using fire to self-harm and commit crime.
Historically we have recorded fatal fires as either fires that are accidental and could
be prevented by education and intervention, or fires that are not accidental and are
as the result of a deliberate human act.
Preventable fatal fires have remained at a five year low, which in large part is
attributable to our work within the community. During the period covered by this
report, this work has included conducting 361,437 Home Safety Checks and
installing 432,861 smoke alarms.
In contrast non-preventable fire fatalities (e.g. those resulting from suicide and
homicide) have increased in numbers and currently stand at a five year high.
Additionally statistics show that the fiscal year 2011/12 was the 1 st year over the
period of the report where non preventable fatalities from fire occurred in greater
numbers than preventable fire fatalities.
Non preventable fires have long been discounted as not warranting any further
research due to their nature. This report clearly identifies that this category of fire
incident is on the increase and therefore requires a significant effort, based on
evidence, to have a positive impact on their reduction.
We want to prevent all deaths that result from fire. To do so we need to challenge
the belief that certain categories of fire cannot be prevented. All fatal fires deliberate
or otherwise must be examined fully to determine their root cause. This approach will
provide the best opportunity to assist us, our partners and our communities to put
measures in place to prevent and positively intervene in the sequence of events that
lead to such incidents occurring.
3

SUMMARY
Over the past 5 years, Greater Manchester Fire and Rescue Service have
investigated 111 fatal fire related incidents. During this period we have observed
preventable fire fatalities decrease by 44%, whereas in the same period we have
observed non preventable fire fatalities increase by 133%.
In 1991 there were 50 preventable fire fatalities in Greater Manchester, last year the
number of preventable fire fatalities had reduced to 10. This fantastic reduction can
be attributed to the proactive approach taken by the Service, to identify those at
highest risk from fire, to help them understand the behaviours and attributes that
place them at risk and to provide them with support through education and/or
equipment to reduce the risk. This has been achieved using our Emergency
Response crews and staff with specialist skills and knowledge who develop and
deliver innovative programmes and initiatives directly in our communities.
We believe that we can continue to build on this success. However this cannot be
achieved in isolation and our ability to influence behaviour to further reduce the
number of preventable fire fatalities, and reverse the trend in non-preventable fire
fatalities can only be delivered through a partnership approach with other agencies
that are engaged with the same risk groups.
Historically, a fire was considered to be ‘preventable’ where it started as a result of
an accident or omission and it was believed that the fire could have been prevented
from occurring if appropriate education and/or advice from the fire and rescue
service and its partners had been provided.
A non-preventable fire was one where a fire started as a result of a deliberate act by
an individual or group, or where a person had died of other causes and then a fire
had occurred. It was believed that it was beyond the control of the fire and rescue
service and its partners to influence the behaviours or circumstances that led to the
fire occurring.
Greater Manchester Fire and Rescue Service believes that all fatalities resulting from
fire can be prevented through early interventions, either directly through the work of
the fire and rescue service, through a joint approach with other agencies or directly
by other agencies. As such the terms ‘Preventable’ and ‘Non-Preventable’, when
used in relation to fatalities from fires are not entirely appropriate but assist us in
identifying those deaths that occur as a consequence of an accidental act or a
deliberate or unforeseen act.
It is intended that this report will be shared with Elected Members, MPs, the Chief
Executives of Local Authorities, Directors of Adult, and Children’s, Services,
Directors of Public Health and the Chairs of Health and Wellbeing Boards to highlight
the common factors that indicate a collective awareness of the risk facing those that
lose their lives in fires. The objective is to place ‘Fire’ at the heart of partnership
arrangements to reduce these risks, thus supporting ‘community budgets’ principles
and providing better value to the communities of Greater Manchester.
4

INTRODUCTION
Over the past 5 years, Greater Manchester Fire and Rescue Service (GMFRS)
attended 23,362 fires in buildings of which 14,825 were dwellings. During these
incidents we rescued 1107 people. However, despite our best efforts, during this
period 60 people lost their lives in preventable fires and 51 died as a result of nonpreventable
fires.
The purpose of this report is to consider preventable and non-preventable fires in
greater detail. It is hoped that data will identify trends and contributory factors which
will support the development of even more effective strategies and tactics to further
reduce the numbers, and consequences, of fires.
Previous studies into fire related deaths support the theory that the majority of fatal
fires we investigate have some form of prior warning sign. If this intelligence was
recognised, identified and shared between the relevant support agencies it may have
resulted in the victim obtaining appropriate support, or intervention, prior to the
incident occurring.
It is our intention within this report to identify possible missed opportunities. We can
then work with our partners, share our findings, and increase their awareness of
support networks available from within GMFRS. We can then work together, more
effectively, to reduce the numbers of fires within communities which result in people
being seriously injured or losing their lives.
5

WHO?
Total number of fire deaths
During the year 1 April 2011 to 31 March 2012, Greater Manchester Fire and Rescue
Service recorded 24 fire related deaths. 10 of these deaths resulted from accidental
fires within the home maintaining a 44% reduction in such incidents since 2007/08,
when accidental fires accounted for 18 fatalities.
In the same period non preventable fires resulted in 14 fatalities; this is a 133%
increase on figures recorded during 2007/08 when 6 members of our community lost
their lives. 2011/12 was the first year during the period covered by this report when
fatalities from non-preventable fires occurred in greater numbers than preventable
fires. This may be explained in part by the lack of prior research into the underlying
causes and contributory factors associated with such incidents, and that it has
previously been the view, held by some, that it was more difficult to prevent, ‘non
preventable’ fire fatalities.
In 1991 there were 50 accidental fire deaths in Greater Manchester. In 2011/12 this
had reduced to 10, which equates to an 80% reduction in such incidents over this
time period.
Throughout the past 10 years, non-preventable fire fatalities have fluctuated from a
peak of 20 fatalities during 2001/02 and the lowest recorded total of 6 during
2007/08. A study of GMFRS data has identified that generally throughout this time
period non preventable fire fatalities have remained in the mid to low teens showing
no measurable trend, and tending to fluctuate year on year.
Total number of fire deaths
20
18
16
14
12
10
8
6
4
2
0
2007/08 2008/09 2009/10 2010/11 2011/12
Preventable Fire Deaths 18 11 11 10 10
Non-Preventable Fire Deaths 6 13 10 8 14
6

Number of fire deaths by age and gender
Gender
Since April 2007, 111 people in Greater Manchester have died in fire related
incidents. 60 members of our community died in preventable fires. Of those 31 were
male and 29 were female.
51 people lost their lives as a consequence of non-preventable incidents of which 27
were male and 24 were female.
Our research shows that there was no evidence to suggest that one particular sex is
significantly more at risk of being involved in such an incident, although figures show
that both categories of fire show slightly more male fatalities than female.
Preventable fire deaths by gender
Period Male Female Total
2007/08 9 9 18
Variation
from
previous
year
2008/09 3 8 11 -7
2009/10 6 5 11 0
% Variation
from 2007/08
2010/11 5 5 10 -1
2011/12 8 2 10 0 -44%
5 Year Total 31 29 60
Non-preventable fire deaths by gender
Period Male Female Total
2007/08 3 3 6
Variation
from
previous
year
2008/09 7 6 13 7
2009/10 5 5 10 -3
% Variation
from 2007/08
2010/11 4 4 8 -2
2011/12 8 6 14 6 133%
5 Year Total 27 24 51
7

Age
Members of our community aged between 41 – 90 accounts for 77% of all fatalities
that have occurred within Greater Manchester over the past five years. In addition,
we have also lost some of our youngest and oldest members of society. Six fire
fatalities involved children under the age of 10 and two persons over the age of 90
lost their lives. Our oldest fatality was aged 101 years.
Preventable fire deaths by age
Age Range 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
0-10 3 1 0 0 0 4
11-20 0 0 0 0 0 0
21-30 1 0 1 1 0 3
31-40 1 0 1 1 0 3
41-50 1 1 2 1 3 8
51-60 3 0 1 1 2 7
61-70 3 2 2 1 2 10
71-80 2 2 2 2 2 10
81-90 3 4 2 3 0 12
91-100 0 1 0 0 1 2
100+ 1 0 0 0 0 1
Total 18 11 11 10 10 60
People aged between 40 and 59 accounted for 29% of all GMFRS fatalities. This
age group represent approximately 27% of the population of England.
People over the age of 60 accounted for just over 51% of all fatalities. This age
group represents 23% of the population within the UK and 21% of the population of
Greater Manchester. These figures identify this age group to be at significant risk of
being involved in a fatal house fire.
8

This risk significantly increases in members of our community above the age of 80
who account for 22% of our fire fatalities, but represent only 4% of the population of
Greater Manchester.
It is also worth mentioning that national statistics show people aged 85 and over 1
account for the fastest population increase within the UK. If this trend continues, it is
anticipated that we will see an increase in fire risk and potentially fire incidents in this
age group.
Non-preventable fire deaths by age
Age Range 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
0-10 0 1 1 0 0 2
11-20 0 0 2 0 1 3
21-30 0 1 0 1 0 2
31-40 1 1 0 0 3 5
41-50 2 3 1 1 3 10
51-60 2 3 0 2 1 8
61-70 1 2 0 1 1 5
71-80 0 1 5 1 2 9
81-90 0 1 0 2 3 6
91-100 0 0 1 0 0 1
100+ 0 0 0 0 0 0
Total 6 13 10 8 14 51
35% of all non-preventable fire deaths occur within the age groups of 41-60.
Fourteen of these fatalities occur as a result of a person utilising fire to end their life.
1 In 1984, there were around 660,000 people in the UK aged 85 and over. Since then the numbers have more than doubled
reaching 1.4 million in 2009. By 2034 the number of people aged 85 and over is projected to be 2.5 times larger than in 2009,
reaching 3.5 million and accounting for 5 per cent of the total population. (Office for National Statistics, June 2011)
9

Ethnicity
Of the 111 fire fatalities, 97 were people whose ethnicity is recorded as White British,
accounting for 87% of all such fatalities. 11 fatalities were from non-white ethnic
groups accounting for 10% of these fatalities.
Members of our community whose ethnicity is recorded as White British account for
84% of the population of Greater Manchester, whereas non-white ethnic groups
make up only 12%. This suggests that fatalities in both groups of ethnicity are
consistent with national totals. (National statistics: Population trends 2007, Population
estimates by ethnic groups 2011)
Preventable fire deaths by ethnicity
Ethnicity 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
White British 15 11 10 8 9 53
Sri Lankan 0 0 0 0 0 0
Indian 1 0 1 0 0 2
Lithuanian 0 0 0 1 0 1
Hungarian 0 0 0 1 0 1
Polish 1 0 0 0 0 1
Somalian 0 0 0 0 0 0
Pakistani 1 0 0 0 1 2
Total 18 11 11 10 10 60
Non-preventable fire deaths by ethnicity
Ethnicity 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
White British 3 9 10 8 14 44
Sri Lankan 1 0 0 0 0 1
Somalian 0 2 0 0 0 2
Pakistani 2 2 0 0 0 4
Total 6 13 10 8 14 51
10

WHEN?
Number of deaths by month, season, day and time
Month
Statistics throughout the five year period showed March (Preventable fire deaths)
and December (Non Preventable fire deaths) as being the months in which most fire
fatalities occurred. Each month recorded 12 fatalities. The months of March and April
accounted for 35% of all preventable fire fatalities.
Preventable fire deaths by month
Month 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
January 1 2 1 0 0 4
February 1 3 1 1 0 6
March 4 2 1 3 2 12
April 3 0 3 2 1 9
May 1 0 1 0 1 3
June 1 1 1 1 1 5
July 2 0 0 1 1 4
August 2 1 0 1 0 4
September 0 0 1 1 2 4
October 0 0 0 0 2 2
November 1 1 1 0 0 3
December 2 1 1 0 0 4
Total 18 11 11 10 10 60
11

June and March (Preventable fire deaths) were the only months in which fire
fatalities occurred during each year of the study, March was also the only month
which recorded more than one fire death during four out of the past five years.
December was the only month to record four unrelated non preventable fire fatalities.
July recorded three fatalities during the year 2009/10, but these December (Non
Preventable fire deaths) recorded the most fatal fire deaths occurring in one month.
This resulted in 5 people losing their lives as a consequence of five separate
incidents during 2011/12.
Non-preventable fire deaths by month
Month 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
January 0 2 0 0 1 3
February 2 1 2 0 2 7
March 0 0 0 1 0 1
April 0 2 0 0 1 3
May 0 0 1 0 0 1
June 2 2 1 1 0 6
July 0 1 3 1 1 6
August 0 0 1 1 0 2
September 0 0 2 0 3 5
October 0 1 0 0 0 1
November 1 2 0 0 1 4
December 1 2 0 4 5 12
Total 6 13 10 8 14 51
12

Season
Statistics do however show some seasonal variations with 63% of preventable fires
occurring in the Winter and Spring seasons. In contrast 69% of non-preventable fires
occurred in the Summer and Winter seasons.
The season of Spring recorded the highest total of preventable fires, but the lowest
total of non-preventable fires.
Winter featured the highest figures for all fatalities accounting for just over 33% of all
fire deaths. Winter months lead to darker and colder nights, resulting in increased
use of heating and lighting within the home. Occupants also tend to spend more time
indoors, exposing the home to a higher risk of fire as a consequence of social habits
such as smoking and drinking.
We must also consider that Winter months may have an impact upon the increase of
non-preventable fires. This time period can have a negative impact upon mental
health and is often associated with financial pressures especially leading up to the
festive period.
Preventable fire deaths by season
Season 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
Spring 7 2 5 5 4 23
Summer 5 2 1 3 2 13
Autumn 1 1 2 1 4 9
Winter 5 6 3 1 0 15
Total 18 11 11 10 10 60
Non-preventable fire deaths by season
Season 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
Spring 0 2 1 1 1 5
Summer 2 3 5 3 0 13
Autumn 1 3 2 0 5 11
Winter 3 5 2 4 8 22
Total 6 13 10 8 14 51
13

Day
Looking at deaths by days of the week identifies that most preventable fatal fires
occurred on Sunday, Monday and Thursday, with Friday and Saturday being the
safest days. It is suggested that fatalities occurring on both Sunday and Monday
morning may be influenced by events occurring in the final hours of the previous
evenings.
Preventable fire deaths by day of the week
Day 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
Monday 2 3 1 5 1 12
Tuesday 2 3 1 0 1 7
Wednesday 3 1 1 0 3 8
Thursday 4 1 1 3 2 11
Friday 1 1 1 1 2 6
Saturday 2 1 2 0 1 6
Sunday 4 1 4 1 0 10
Total 18 11 11 10 10 60
Non-preventable fire deaths by day of the week
Day 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
Monday 1 3 0 0 4 8
Tuesday 0 2 0 2 1 5
Wednesday 0 1 1 3 1 6
Thursday 0 2 5 0 3 10
Friday 3 4 0 1 2 10
Saturday 0 0 3 1 1 5
Sunday 2 1 1 1 2 7
Total 6 13 10 8 14 51
14

During the period of the report, most non-preventable fire fatalities occurred during
Thursday and Friday. One incident occurred on a Thursday in which three members
of our community lost their lives. This incident occurred during 2009/10 and it is
believed that the ignition of this fire was influenced by a previous history of domestic
abuse and the consumption of alcohol the previous evening.
All fatalities that occurred on Friday were as a consequence of ten separate
incidents.
15

Time
Fire deaths have occurred within all defined time scales throughout the 24 hour
period in both categories of fire. Most preventable fire deaths within a single time
period occurred between the hours of 18:00 and 20:00, accounting for 20% of
preventable fire fatalities over this five year period.
Between the hours of midnight and 08:00, 21 fatalities were recorded accounting for
35% of all preventable fire fatalities. It is considered that during this time period
occupants will be unlikely to discover a fire in its early stage of development due to
being asleep. It is therefore necessary to ensure that all properties within Greater
Manchester are fitted with sufficient smoke detection to ensure fires are discovered
in the early stages of development and sufficient warning is provide to occupants.
We must ensure that we provide a level of protection to vulnerable individuals and
families sufficient to address their risk. To achieve this we must ensure that Home
Safety Checks are conducted in a professional manner to ensure all risks within the
home are identified and fed back to the appropriate agencies and departments.
Partnerships with support agencies who engage with vulnerable people should
include reciprocal education and communication to ensure that risks they have
identified are communicated back to GMFRS. A lack of awareness may mean that
partner agencies do not identify fire risk indicators and may not appreciate the
serious consequences that can result. It is our responsibility to seek out opportunities
to educate key partners and establish robust partnership arrangements so that fire
risk can be detected early and appropriate interventions can be offered.
Fire deaths by time of day (5 year total)
Preventable fire deaths
Non-preventable fire deaths
12
10
8
6
4
2
0
Time range (24hr)
Note: A late fire call (LFC) is one that isn’t received at the time of the fire but is received
some time later, usually after the fire has been extinguished. This can occasionally be a
number of days after a fire has occurred.
16

Time (24hr) 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
0000-0200 5 0 2 0 1 8
0200-0400 0 0 2 1 0 3
0400-0600 1 1 0 4 0 6
0600-0800 1 1 0 1 1 4
0800-1000 2 2 0 1 0 5
1000-1200 2 1 2 0 1 6
1200-1400 0 0 0 0 2 2
1400-1600 0 1 1 1 0 3
1600-1800 0 2 0 1 1 4
1800-2000 2 3 4 1 2 12
2000-2200 3 0 0 0 0 3
2200-0000 2 0 0 0 0 2
Undetermined
Time (LFC)
Preventable fire deaths by time of day
0 0 0 0 2 2
Total 18 11 11 10 10 60
The time period in which most non preventable fatalities occurred, was between
04:00 and 06:00. During this period 8 people lost their lives, three as a result of one
incident that occurred during the fiscal year 2011/12.
Time (24hr) 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
0000-0200 0 1 0 1 1 3
0200-0400 0 1 0 0 0 1
0400-0600 0 0 3 1 4 8
0600-0800 0 0 2 1 0 3
0800-1000 0 2 1 0 1 4
1000-1200 1 0 0 1 0 2
1200-1400 0 2 0 0 1 3
1400-1600 2 1 1 0 1 5
1600-1800 0 1 0 0 3 4
1800-2000 0 2 0 2 1 5
2000-2200 0 1 0 1 1 3
2200-0000 2 2 0 1 1 6
Undetermined
Time (LFC)
Non-preventable fire deaths by time of day
1 0 3 0 0 4
Total 6 13 10 8 14 51
17

The potential for loss of life will be increased when properties are targeted by
deliberate fires during the hours when occupants are sleeping. During the time
period of this report, all deliberate multiple fatal fires, where time of ignition has been
clarified, occurred between the hours of 23:00 and 06:00.
It is therefore important that accurate pictures of risk involving members of our
community are identified. This will allow GMFRS to provide the most appropriate risk
reduction strategies and interventions to address the risk.
The provision of fire risk reduction equipment is one type of intervention and may
consist of portable suppression equipment (sprinklers) and square wave smoke
alarms. These alarms provide a low-frequency square wave signal which has been
found to be significantly more effective in warning members of our community who
may be hard-of-hearing or impaired by alcohol.
18

WHERE?
Number of deaths by borough
The following tables show the distribution of both preventable and non-preventable
fatalities across the ten boroughs of Greater Manchester (Manchester is split into
North and South for statistical purposes). During 2011/12 there were no recorded
preventable fire deaths in Bury, Manchester South, Tameside and Oldham, but
comparison over a five year period identifies that Tameside, Wigan and Oldham
suffered the highest levels of fatalities.
Boroughs continue to work towards breaking down barriers with health and social
care agencies to assist in the process of identifying people at increased risk of fire,
within their community, and providing them with necessary assistance.
They have been innovative in creating campaigns to address the increase in clothing
related fires and continue to educate regarding the dangers of cooking related
incidents. They have also identified the need for continued interaction with one
borough identifying that 40% of their fires occurred in properties which had already
undergone a HSC.
19

Preventable fire deaths by borough
Borough 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
Bolton 0 1 0 1 2 4
Bury 1 1 0 0 0 2
Manchester Noth 3 0 0 2 1 6
Manchester South 2 0 2 0 0 4
Oldham 4 1 0 1 0 6
Rochdale 1 0 2 1 2 6
Salford 2 0 0 3 2 7
Stockport 1 0 1 2 1 5
Tameside 3 3 1 0 0 7
Trafford 0 1 4 0 1 6
Wigan 1 4 1 0 1 7
Total 18 11 11 10 10 60
During the years 2007/08 – 2010/11 Trafford was the only borough not to record any
non-preventable fatalities. This trend ceased as a consequence of a multiple fatal
incident during 2011/12.
Non-preventable fire deaths by borough
Borough 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
Bolton 1 4 0 0 2 7
Bury 1 0 2 1 1 5
Manchester Noth 1 2 4 1 0 8
Manchester South 0 2 0 2 1 5
Oldham 1 2 0 1 0 4
Rochdale 0 0 1 0 1 2
Salford 1 0 1 1 1 4
Stockport 1 1 0 1 2 5
Tameside 0 1 0 0 2 3
Trafford 0 0 0 0 3 3
Wigan 0 1 2 1 1 5
Total 6 13 10 8 14 51
Throughout the period covered by this report no single borough has recorded zero
fatalities in either preventable or non-preventable incidents. In total Manchester
North has recorded the most combined fatalities with a total of 14 deaths, with Bury
recording the least fatalities with 7 deaths.
20

Deaths by property type 2
Tables below illustrate that 90% of non-preventable fire fatalities have occurred
within the home, mostly within terraced, flats/maisonettes and semi-detached
properties.
Terraced property makes up 33% of the housing stock in Greater Manchester but
accounts for 39% of all fire fatalities.
Preventable fire deaths by property type
Property type 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
Aircraft 0 0 0 0 1 1
Bungalow 3 0 0 1 1 5
Caravan 0 0 0 1 0 1
Care Home 0 1 1 0 0 2
Detached 0 1 0 0 0 1
Factory 0 0 0 0 1 1
Flat 5 2 3 2 2 14
Semi Detached 2 1 3 2 1 9
Shed 0 0 0 2 0 2
Terraced 8 6 3 2 4 23
Public House 0 0 1 0 0 1
Total 18 11 11 10 10 60
2 Research shows that there are approximately 1,105,000 households within Greater Manchester, serving a population of
2,572,000. (Greater Manchester Strategic Housing Market Assessment, May 2010)
21

Figures show that detached properties are of a lower risk compared to other
dwellings. They represent 14% of housing stock, however only 4.5% of fatalities
occurred in these dwellings.
It could be argued, that this reduction in risk could be as a consequence of the
residents of such properties being more affluent and less socially deprived. They
may have an increased awareness of fire risk within the home, and as a
consequence take necessary actions to reduce this risk.
Non-preventable fire deaths by property type
Property type 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
Care Home 0 1 0 0 0 1
Detached 0 0 3 1 0 4
Flat 1 3 2 0 3 9
Motor Vehicle 0 1 0 2 0 3
Open Land 0 2 0 0 1 3
Semi Detached 1 1 3 2 4 11
Terraced 4 5 2 3 6 20
Total 6 13 10 8 14 51
22

Location within property
Of the 111 people that died in fire related incidents, during the period covered by this
report, 37 died within the lounge of the property. These figures account for 33% of all
fatalities.
Both categories of fire death identify that the bedroom and lounge are the most
common locations for such incidents to occur, accounting for 58% of all fatal fires.
Preventable fire deaths by location within property
Location 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
Bathroom 0 0 1 0 0 1
Bedroom 7 0 4 0 3 14
Dining room 0 1 0 0 0 1
Engine compartment 0 0 0 0 1 1
Hallway 0 0 0 1 0 1
Kitchen 1 1 3 3 3 11
Lounge 10 7 2 4 2 25
Office 0 1 0 0 0 1
Processing room 0 0 0 0 1 1
External 0 1 1 2 0 4
Total 18 11 11 10 10 60
23

16 fatalities occurred in locations outside of a domestic setting. Seven of these
fatalities were as a consequence of a person deliberately using fire as a means to
commit suicide.
Non-preventable fire deaths by location within property
Location 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
Bathroom 0 2 0 0 0 2
Bedroom 1 1 5 3 3 13
Dining room 0 0 0 0 1 1
Garden/yard 1 0 0 0 1 2
Hallway 1 1 0 0 0 2
Kitchen 1 4 2 1 1 9
Landing 0 0 0 0 3 3
Lounge 2 2 3 2 3 12
Motor vehicle 0 1 0 2 0 3
Open land 0 2 0 0 1 3
Outhouse 0 0 0 0 1 1
Total 6 13 10 8 14 51
24

WHY?
This section discusses the three types of deaths as recorded by HM Coroner; which
are accidental death, death by natural causes and a death by intervention.
An accidental death is considered to be an unforeseen and unplanned event or
circumstance, often with lack of intention or necessity. It usually implies a generally
negative outcome, which may have been avoided or prevented had circumstances
leading up to the accident been recognised, and acted upon, prior to its occurrence.
A death by natural causes is one that is primarily attributed to natural agents: usually
an illness/infection or an internal malfunction of the body, such as a heart attack.
Death caused by active intervention is called an unnatural death. The causes
attributed to such a death are usually given as an accident (implying no
unreasonable voluntary risk), misadventure (accident following a wilful and
dangerous risk), suicide (the intentional taking of one's own life), or homicide.
Throughout the previous five years the Fire Investigation Team has investigated 111
deaths. 60 deaths have been attributable to accidental causes. Throughout the
previous 5 years Careless Use/Disposal of Smoking Materials (CDSM) have
accounted for 42% of all preventable fire fatalities within Greater Manchester.
25

Preventable fire deaths by direct cause
Location 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
Candles 2 0 0 2 0 4
CDSM 10 4 4 4 3 25
Chip pan 0 0 1 2 2 5
Cooker left unattended 0 0 0 1 0 1
Drug preparation 0 1 1 0 0 2
Electrical 1 1 1 0 1 4
Ignition of accelerant/vapours 0 0 1 0 1 2
Microwave wheat bag 0 0 1 0 0 1
Radiated heat/contact with flame 5 5 2 1 2 15
Spark from machine 0 0 0 0 1 1
Total 18 11 11 10 10 60
Investigation into fatal fires, which occurred as a consequence of CDSM and cooking
related incidents have frequently identified that several other contributory health or
lifestyle factors have been present. These factors often involved the consumption of
alcohol and the victim living alone. This reduced the likelihood of early discovery or
escape, particularly where the occupant had some form of disability and would have
required assistance to escape.
Fires involving CDSM have shown a continued reduction during the period covered
by this report. During 2011/12, CDSM accounted for 30% of all preventable fire
deaths, which is a considerable reduction from figures recorded in 2007/08, where
10 members of our community died and CDSM accounted for 56% of all preventable
fatal fires.
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Preventable fire deaths contributing factors
Contributing factor 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
Alcohol 6 2 6 6 5 25
Recreational drugs 0 0 2 0 0 2
Living alone 4 4 7 6 8 29
Smoking materials 10 4 4 4 3 25
Physical disability 3 3 2 5 5 18
Social service 4 1 6 3 5 19
Prescribed medication 3 1 6 4 6 20
Mental illness 3 3 4 0 1 11
Non-preventable fire deaths by direct cause
Location 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
Deliberate by occupier 0 0 5 0 1 6
Deliberate by third party 0 3 0 1 3 7
Natural causes 2 3 5 3 6 19
Suicide 4 7 0 4 4 19
Total 6 13 10 8 14 51
Nineteen of our non-preventable fire fatalities were considered to have occurred as a
result of a natural cause, following which an accidental fire has developed. These
fires usually develop as a consequence of a person’s activities prior to ignition, such
as smoking or cooking.
The act of suicide has accounted for 37% of all non-preventable fire fatalities within
Greater Manchester. This category of fire has been frequently associated with a
number of contributory factors, which will be discussed later within this report.
27

Thirteen people have died as a result of deliberate fires set by either an occupier of
the property or a third party. All deaths relating to deliberate fires set by an occupier
occurred during the years 2009/10 and 2011/12. This consisted of three incidents
resulting in six fatalities. The investigation into one of these incidents resulted in a
family member being convicted for manslaughter.
Seven people have died as a result of deliberate fires set by a third party. One of
these incidents resulted in two fatalities and three firefighters suffering injuries - one
sustaining life threatening burns. A further incident involved three fatalities in which
the offender died as a consequence of the fire they started.
Two additional deliberate fatal fires occurred during this time period, but are not
recorded within this report. The reason for this absence is that these incidents were
confirmed as being non fire related deaths. The victims were confirmed deceased
prior to the fire occurring, which had been ignited to conceal a prior murder.
Non-preventable fire deaths contributing factors
Contributing factor 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
Alcohol 1 2 2 4 6 15
Recreational drugs 0 0 1 1 0 2
Living alone 2 2 3 2 9 18
Smoking materials 2 0 4 2 3 11
Physical disability 2 2 4 3 5 16
Social service 0 3 4 2 7 16
Prescribed medication 4 5 4 3 7 23
Mental illness 6 6 0 1 2 15
Contributory factors relating to both categories of fire identified that many of the
victims had some involvement with, or were known to partner agencies. In many
cases support was being received for mental health problems alcohol dependency
and domestic abuse. As mentioned previously some partners are not aware or do
not engage effectively with GMFRS who can support them with fire risk assessment
and management. It is clear from examining the types of contributory factors
associated with fatal fires that GMFRS need to work with those individuals who are
often known to other agencies. We therefore need to focus our prevention work on
targeting the services that support these individuals to raise awareness about the
link to fire, and to develop sustainable partnership working.
Contributory factors relating to non-preventable fires have identified that many
individuals had the potential to be identified to GMFRS as a consequence of being
known to, or under the care of, support agencies. Non preventable fires may be
prevented by exploration of a person’s lifestyle. This may lead to a death by natural
causes, depression that may result in a person committing suicide or physical abuse
with fire being used to cause harm to themselves or to a third party.
28

We need to explore with our partners how we can work together to identify
opportunities to intervene in such a sequence of events. This approach is vital to
ensure appropriate support is identified and provided at the earliest opportunity.
Smoke detection
Survey research shows that the proportion of households with a smoke alarm
increased rapidly from 8% in 1988 to 70% in 1994, but has risen more slowly in later
years up to 86% in 2008.
In 2010/11, a smoke alarm raised the alarm in 36% of reported dwelling fires. This
continued the general increase since 2000 when smoke alarms raised the alarm in
only 25% of reported fires (Fire Statistics, 2010/11).
Dwelling fires in which smoke alarms raise the alarm continue to:
1. Be discovered more rapidly after ignition
2. Be associated with lower fatal casualty rates
3. Cause less damage as they are more often confined to the item first ignited.
Preventable fire deaths by smoke detection
2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
Total fire deaths 18 11 11 10 10 60
Smoke alarm installed 14 9 9 7 6 45
Smoke alarm not installed 4 2 2 3 4 15
Of the smoke alarms installed
Smoke alarm functioning 9 3 4 5 4 25
Smoke alarm not functioning 3 3 5 2 2 15
Unknown 2 3 0 0 0 5
45
29

Of the 55 people who died in preventable dwelling fires within Greater Manchester,
45 of them lived in properties fitted with smoke alarms. Only 25 of those properties
however were protected by a working smoke alarm. Of these 25 operational alarms it
has to be considered that contributory factors such as the effects of alcohol and
disabilities may have prevented the occupier from responding effectively when
alerted. It is therefore important that prevention activity is tailored to meet the needs
of the individual as a one size fits all approach is not sufficient. GMFRS along with
our partners must look at alternative solutions involving technology and specialist
alarms such as the square wave alarm or equivalent. It must also be considered that
some of the smoke alarms that were in situ may have been fitted in inappropriate
locations to manage the risk effectively.
Fire Investigators have identified that on many occasions residents are forced to
reassess the way they live within their properties due to a change in circumstance
e.g. reduced mobility. Smoke alarm provision has not been reassessed to reflect
such changes in circumstances.
Fifteen alarms had been installed in properties, but were found to be defective.
These findings are disappointing as it would appear that smoke detection is being
fitted but not being maintained. The main reasons for smoke alarms failing to
activate was that they had missing or flat batteries, or the unit being unable to detect
the products of combustion, resulting from improper installation or being incorrectly
located.
The table identifies that during the course of the study the occurrence of deaths in
properties without smoke alarms has increased. It is considered that this may be as
a consequence of a small percentage of the community not having been provided
with a HSC.
GMFRS must undertake necessary action to identify this hard to reach group and
provide them with necessary fire prevention advice and smoke alarm provision
Note: It is important to remember that these figures do not include the many occasions when
smoke alarms have alerted the occupier and allowed them and their families to safely
escape the property.
30

Suicide
Gender
The act of Suicide has accounted for 37% of all non-preventable fire fatalities within
Greater Manchester and along with Natural Causes is the largest cause of nonpreventable
fire fatalities.
Statistics produced over the past five years do not identify a particular gender being
at greater risk of committing such an act.
Suicide by gender
Period Male Female 5 Year Total
2007/08 1 3 4
2008/09 3 4 7
2009/10 0 0 0
2010/11 3 1 4
2011/12 2 2 4
5 year total 9 10 19
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Age
74% of all fire related suicides involved members of our community aged between 41
and 60. This is a significant finding, which requires further investigation by GMFRS
and its partners to identify the contributory factors which place these age groups at a
greater risk.
Suicide by age
Age Range 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
0-10 0 0 0 0 0 0
11-20 0 0 0 0 0 0
21-30 0 1 0 1 0 2
31-40 1 1 0 0 0 2
41-50 2 2 0 1 3 8
51-60 1 2 0 2 1 6
61-70 0 1 0 0 0 1
71-80 0 0 0 0 0 0
81-90 0 0 0 0 0 0
91-100 0 0 0 0 0 0
100+ 0 0 0 0 0 0
Total 4 7 0 4 4 19
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Location
This table shows that of the 19 people that have died as a result of suicide, 12 have
died within a dwelling. Of these, 67% occurred within the kitchen or bedroom.
Remote from the property, 3 suicides occurred within a motor vehicle, one in an
outhouse and 2 on open land. All of these incidents involved the use of an ignitable
liquid to accelerate the fire.
Suicide by location within property
Location 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
Bedroom 0 2 0 1 1 4
Garden/yard 1 0 0 0 0 1
Hallway 1 0 0 0 0 1
Kitchen 1 2 0 1 0 4
Landing 0 0 0 0 1 1
Lounge 1 0 0 0 1 2
Motor vehicle 0 1 0 2 0 3
Open land 0 2 0 0 0 2
Outhouse 0 0 0 0 1 1
Total 4 7 0 4 4 19
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Cause
Records over the past 5 years show self-immolation being the main cause of deaths
attributed to the act of suicide. Self-immolation is defined as the deliberate sacrifice
of oneself by fire, and accounted for 68% of all fatalities.
Suicide by direct cause
Direct cause 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
Deliberate ignition of
BBQ indoors, resulting 0 0 0 0 1 1
in fire
Deliberate activation
of explosive device
0 0 0 1 0 1
Delibrate ignition of
dwelling whilst inside
0 2 0 0 1 3
Deliberate ignition of
vapours
0 0 0 0 1 1
Self-immolation 4 5 0 3 1 13
Total 4 7 0 4 4 19
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Contributory factors
There are many factors, which may contribute to someone taking their own life by
fire. Many people that do so are already known to other agencies and are already
being provided with support and care. They may also upon investigation have
previously attempted to end their own life, albeit not with the use of fire.
There are also instances though, when investigations into these fires identify that a
person had not been under the care of partner agencies, nor displayed any
behaviour consistent with wanting to take their own life. It is this category of person
that represents the greatest challenge for partner agencies to identify and provide
with necessary support.
The investigation into these incidents identified that mental illness, particularly
depression, was the largest single contributory factor involving fire related suicides.
This category predominantly involved female members of our community.
Only three male non preventable fire victims displayed any evidence of mental
illness. During our investigations into these deaths we were unable to determine if
mental illness had been diagnosed by a doctor or the individual was considered to
be depressed by loved ones. The investigation of these fires revealed no evidence of
prescribed medication.
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Contributing factor
Suicides by contributing factors
2007/08 2008/09 2009/10
2010/11 2011/12 5 year total 5 Year
Total
M ale F emale M ale F emale M ale F emale M ale F emale M ale F emale M ale F emale
Alcohol 0 0 2 0 0 0 1 0 1 2 4 2 6
Recreational drugs 0 0 0 0 0 0 1 0 0 0 1 0 1
Mental health/depression 1 4 2 3 0 0 0 1 0 2 3 10 13
Physical disability 0 0 1 0 0 0 0 1 0 0 1 1 2
Prescribed medication 0 2 0 2 0 0 0 1 0 2 0 7 7
Social services 0 0 0 2 0 0 0 0 1 2 1 4 5
Total 1 6 5 7 0 0 2 3 2 8 10 24 34
36

Coroner verdict
HM Coroner will not always attribute a death to suicide even though a person has
performed an act of deliberately setting fire to themselves or deliberately setting fire
to a property they occupied then made no attempt to escape.
The Coroner will in certain circumstances consider that other factors may have
contributed to this death; therefore the person may not have fully understood the
consequences of their actions. This may lead them to record at Inquest an open
verdict (Open verdict, a finding by HM Coroner without stating the cause, where
there is insufficient evidence to record any of the other verdicts, i.e. the evidence
fails to meet the required proof) or death by misadventure (a lawful human act, which
takes an unexpected turn and leads to death).
The Fire Investigation team are required to attend and provide evidence at all HM
Coroners Inquests. They will record the Coroners verdict, but will still determine an
act of self-immolation under the category of suicide for our own purposes unless the
Coroner determines it to be an accidental death or deliberate by third party.
Coroner suicide verdict
Verdict 2007/08 2008/09 2009/10 2010/11 2011/12 5 Year Total
Suicide 3 3 0 1 2 9
Misadventure 1 1 0 2 1 5
Open 0 3 0 1 1 5
Total 4 7 0 4 4 19
GMFRS attend the Greater Manchester Suicide Prevention Partnership which is a
multi-agency forum that provides us with access to partners with a specific interest in
suicide and suicide prevention. Our aim is to assist our partners in sharing
information and developing suitable support mechanisms and initiatives that can
used to reduce the risk of these incidents occurring.
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Conclusions
This report presents a wealth of information that has been gathered regarding the
circumstances surrounding fatalities from fire in Greater Manchester over the last
five years. It also shows that we have had significant successes in reducing the
number of preventable fire fatalities. However the overall numbers of fire fatalities
has not reduced in a similar way, due to the marked increase in the number of nonpreventable
fire fatalities over the same period.
This report identifies a number of issues for further consideration including:
The risks of dying as a result of fire increase significantly with age and there are
specific age groups that consistently demonstrate this risk e.g. 41-60 for nonpreventable
fire fatalities, 81-90 for preventable fire fatalities
Preventable fire fatalities appear to peak during the Spring with non-preventable
fire fatalities peaking during the Winter, with a significant number of these
occurring during December
Manchester Borough experiences the highest number of preventable and nonpreventable
fire fatalities, it also has the highest population of any borough in
Greater Manchester
Both preventable and non-preventable fire fatalities are significantly more likely
to occur in terraced housing. It is unlikely that this is attributable to the property
type but may be of relevance if other factors, such as lifestyle, deprivation and
educational achievement are also considered
Careless use of smoking materials and contact with a flame or radiated heat are
by far the most significant direct causes of fires that result in preventable
fatalities, with natural causes and suicide being the most significant causes of
non-preventable fire fatalities
Living alone, use of alcohol and smoking are the most prevalent contributory
factors in preventable fire fatalities. The distinction between contributory factors
is more difficult to identify when considering non-preventable fire fatalities,
however the presence or use of prescription medicines has been a factor in over
50% of all such fire fatalities
Although there has been a significant reduction in the number of preventable fire
fatalities, it remains the case that the majority of preventable fire fatalities occur
in properties that either have not had a smoke alarm fitted or the smoke alarm
has been defective
The number of fatalities where fire has been used as a means of committing
suicide has remained relatively unchanged during the period of the report. This is
an approach that is predominantly used by those aged between 41 and 60, with
mental health being the most significant contributory factor and self-immolation
being the most prevalent method used
38

The information presented provides Greater Manchester Fire and Rescue Service an
opportunity, with its’ partners, to develop and deliver appropriate strategies and
tactics to further reduce the impact of fire on our communities whilst simultaneously
meeting the aims of a number of agencies.
Recommendations
1. Share this report with elected officials, and our statutory partners, to influence
greater involvement, by GMFRS, in partnership arrangements to reduce overall
risk within our communities
2. Develop and implement a consistent approach to supporting those that are at a
higher risk from fire as a result of threats or violence. Particular attention should
be paid to consistency of approaches with Victim Support, Witness Support and
through the Multi Agency Risk Assessment Conference (MARAC) process.
3. Through our Corporate Planning and Intelligence (CPI) Directorate, commission
analysis/research to consider whether there are any emerging combinations of
contributory factors contained within the report that are more likely to lead to
either a preventable or non-preventable fire fatality.
4. Through our team of Central Prevention Coordinators, develop campaigns and
initiatives to address the findings of the analysis/research referenced above.
5. Further develop our relationships with partners such as Age UK, Health/Mental
Health service providers and Suicide Prevention Partnerships, to identify why the
number of non-preventable fire fatalities is rising and to support those individuals
most at risk from fire.
6. To provide a more robust measure of rates of fire related fatalities, introduce
reporting and measurement of fire fatalities by Borough, on a per capita basis.
7. To provide a statistically valid evidence base for our future activities, expand the
role of Fire Investigators within Greater Manchester, to include more detailed
recording and reporting of information from fires (preventable and nonpreventable)
that have resulted in serious injuries.
8. To support the work of our CPI Directorate, train our Fire Investigators to
undertake the role of interviewers as part of the Post Incident Research project.
39