It’s heartbreaking to think that a tiny device meant to keep people safe could end up falling short in the worst possible way.
That’s exactly what happened to Caroline and Bernard Cleall, an elderly couple in their seventies who lost their lives in a devastating house fire in Addiscombe, south London, back in January 2022.
Despite pressing a panic button, they couldn’t get the urgent help they desperately needed—because the smoke alarm going off in their home wasn’t heard by the emergency call operator.
How the Emergency Response Fell Through the Cracks
The trouble began when Mrs. Cleall, trapped in the sitting room engulfed by smoke, pressed her emergency pendant button.
Unfortunately, she wasn’t able to communicate effectively with the call handler.
At the same time, her husband was overcome by smoke and unable to assist.
A smoke alarm was blaring in the room, but the operator on the other end of the call never heard it.
Instead of the fire brigade being dispatched immediately, emergency care responders were sent first.
The firefighters were only called once the responders arrived and confirmed the fire—but by then, it was tragically too late to save the couple.
What Kind of Care Package Did Mrs. Cleall Have?
Mrs. Cleall’s care package was arranged by Croydon Adult Social Care in September 2021, with support from an NHS group called Living Independently For Everyone (LIFE) Services.
Part of her package included a Careline emergency alarm pendant.
But here’s the crucial part: she was given a basic telecare package.
This package only provided a call operator, and did not include an automatic smoke detector that could alert emergency services instantly without needing her to push a button.
Had she been on a more advanced package, the fire brigade could have been alerted automatically when the smoke alarm went off.
What the Coroner Discovered
Ivor Collett, the Assistant Coroner for South London, investigated the tragic deaths and concluded they were accidental.
However, he expressed serious concerns about the emergency alarm system provided.
He explained that Mrs. Cleall’s pendant button was pressed during the fire, but communication with the call operator was ineffective due to where she was trapped in the house.
Meanwhile, the operator didn’t hear the smoke alarm, which was sounding loudly.
Because of this, emergency care responders were sent first—not the fire service.
Collett noted that telecare services should, by default, offer enhanced packages that include automatic smoke detectors.
These detectors would send urgent signals directly to the call operator without any action from the user, instantly alerting the fire brigade.
This is exactly the kind of system that could have saved the Clealls.
Missing Information and Poor Communication
Another major concern was that Croydon Adult Social Care couldn’t access Mrs. Cleall’s assessment records from Croydon University Hospital.
These records were stored on an NHS system that the social care team didn’t have access to.
Because of this gap, the coroner said there was no clear evidence that Mrs. Cleall was properly advised about the level of telecare package she should have had.
If she had declined a more advanced package despite advice, that decision should have been documented—but no such records were found.
Even a follow-up review done weeks after Mrs. Cleall’s hospital discharge apparently lacked vital information, which could have influenced whether her care package needed upgrading.
What Needs to Change?
The coroner emphasized that without access to earlier assessments and advice, social care professionals are unable to fully review and meet the needs of vulnerable clients like Mrs. Cleall.
This communication breakdown between NHS teams and social care services can have deadly consequences.
A Prevention of Future Deaths report was sent to the London Borough of Croydon, demanding answers and action within 56 days.
What’s Next?
The hope is that Croydon Adult Social Care will respond by improving their systems, ensuring better communication, and recommending enhanced telecare packages that include automatic smoke detectors as standard.
This tragedy highlights how crucial it is to get the right safety equipment in place—and make sure it works exactly when it’s needed most.