An elderly woman killed after a fire destroyed a retirement home died as a result of a “tragic accident”, a coroner has ruled.

Irene Cockerton, 87, died after a fire started two doors away from her flat at Gibson Court, Manor Road North, Hinchley Wood, in the early hours of September 30, 2011.

She was the only resident not to reach safety and was found by rescue crews the following day in her wardrobe, where she is believed to have taken shelter.

Coroner Richard Travers said today he was satisfied that damaged fire curtains in part of the roof space of the property were brought to the attention of management in June 2010.

The curtains, the damage to which was “not simple”, were not repaired until February 2011 and the inspection of the works was “limited”, but Mr Travers said “one will never know if adequate works had taken place”.

Your Local Guardian: Fatal fire: Gibson Court on the night

The fire at Gibson Court in 2011

Referring to the annual fire risk assessment at the property, owned by Peverel Retirement, Mr Travers said it was “pitiful, flawed and inaccurate” as the area manager had never entered the roof space to check the conditions of the fire precautions.

Mr Travers said: “The area manager told me in evidence he had never been in to the roof and did not know if the roof void was divided and if so, what condition the precautions were in.”

Mr Travers also raised concerns that on the night of the fire, details from two other emergency calls, one about smoke to Careline and another about the sound of breaking glass to 999, were not passed onto the fire service who were extinguishing the blaze.

He said: “It is important to remember at that stage there was no reason to think the fire in flat 25 would not be under control.

"It was considered to be manageable at that stage.”

The coroner said house manger Marion Debeer mirrored that fact by giving tea and biscuits to residents rather than evacuating them.

But the fire spread quickly across the roof space and within 75 minutes, part of the roof had collapsed.

Your Local Guardian: The care home on Friday morning.

Coroner Richard Travers described Peverel's fire risk assessment as “pitiful, flawed and inaccurate"

Mr Travers said: “The tragic reality is by the time anyone realised Mrs Cockerton was missing, it was too late to come to her rescue.”

But Mr Travers said there was no evidence to suggest the condition of the fire curtains in the central roof space and whether that contributed to the “rapid” fire spread.

Concerns were also raised about Peverel’s 'stay put' policy, which was deemed “more risky” than causing anxiety to residents by evacuating them. Delivering his conclusion, Mr Travers said: “Mrs Cockerton died as a result of a tragic accident and I record a conclusion of accidental death.

“Although Irene Cockerton’s life very sadly was not saved, through this inquest light has been thrown on the current practices and firefighters risked their safety by returning to the building, which was very unsafe, to rescue a lot of vulnerable people who almost certainly would have perished otherwise.”

Mr Travers said he would write to relevant agencies expressing concerns about carrying out effective fire risk assessments of the roof void at Peverel properties; the communication between the emergency control room and firefighters at the scene; the speed at which emergency calls made to Careline are transferred to the emergency control room, using a stay put policy where residents are elderly and the positioning of smoke alarms within individual flats.

Your Local Guardian: Newly refurbished Gibson Court in 2014

Gibson Court only reopened in summer 2013 following the fatal fire

Speaking after the inquest, Martin Fox, Mrs Cockerton’s son-in-law, said: “We are happy with the decision that has been made. We thought it was accidental but we did think there was significant problems with the building and we still think that.”

Asked about the stay put policy in place at Gibson Court, Mr Fox said he and his wife felt it was “a bit strange.”

He said: “I think things should have happened quicker. If things had happened quicker, I think she would still be here. I think the fire service were great and they did a very good job and I am full of praise for them.

“We will remember Irene as a lovely woman who loved life. She loved living at Gibson Court and we still miss her terribly.”

A Peverel Retirement spokesman said: “We are extremely saddened by the tragic death of Mrs Cockerton at Gibson Court in September 2011. “The safety and wellbeing of all our customers is our utmost priority. We will give all due consideration to the coroner’s conclusion and any subsequent reports to identify if there are any areas where further improvements can be made.”

The spokesman said they would not comment further on the inquest.

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