A wheelchair-bound great-grandfather is thought to have died alone in a Bupa care home after smoking a cigarette and catching on fire, an inquest heard.
There were no witnesses to the death of Cedric Skyers, 69, who died in the garden of the Bupa-run Manley Court care home in New Cross, south east London in March last year.
Mr Skyers could not use his left-hand side after a suffering a stroke and had limited mobility, the inquest into his death at Southwark Crown Court heard.
His son David Skyers, 38, wants answers about various matters including his care plan supervision, his burns and whether a risk assessment was done.
Coroner Dr Andrew Harris told him at the start of his father's inquest: "These are all matters which I hope this evidence might provide some answers to."
The coroner later noted that "one of the benefits of this terrible tragedy is that there is better equipment and better awareness" on the part of Bupa of how to manage fires.
Nurse Odion Upasen Imieh, who carried out cardio pulmonary resuscitation on Mr Skyers, repeatedly broke down as she remembered him as a "funny" and "lively" man.
Pointing out the changes which have been imposed since his death, she told the court: "I always check residents' clothing to make sure there is no cigarette burns on their clothing.
"I ask the staff to report anything found to me.
"I always make sure they (the residents) wear aprons that are provided by the home - they are fire retardant.
"I make sure the garden is safe and there is no litter and the fire bucket is in place as well."
Jamaican-born Mr Skyers was a retired labourer who had four children, three grandchildren and a great-grandchild.
He was a poetry lover who was still mentally capable and able to speak, according to his son David.
He told the inquest that his father "certainly had the capacity to light a cigarette" despite the pain he felt in his arm and leg.
The hearing was adjourned until Tuesday at 9.30am.
Additional reporting by Press Association.