"Exactly what he intended to do with this kindling wood he had acquired it is not known. Although Mr Hall could not exactly be described as a fire bug, his casual observation of the rules relating to smoking at the very least made his conduct a fire risk."
The residential care units, called Kahu Kura, are maintained and operated by Whatever It Takes Inc, a charitable trust.
The trust had a fire evacuation plan in place and two fire alarms installed in each unit, however there had not been any fire drills or training.
The fire alarms in Mr Hall's unit had been activated falsely a number of times leading up to his death.
Between February 4 2012 and March 13 2013 there were 16 alarm activations from the unit.
Fifteen of these were false and the final activation was the fire that resulted in Mr Hall's death.
Three of the activations occurred before Mr Hall's occupation of the unit.
On the night of Mr Hall's death there was one caregiver in charge of nine residents.
Just before 5am the alarm went off in Mr Hall's unit and the caregiver went to see why.
"She didn't expect a fire, she thought it would be a false alarm," Mr Scott wrote.
When she got to the unit she managed to pull the sliding door open slightly and thick, black, toxic smelling smoke poured out. She could not gain entry and instead went and evacuated residents around the unit before calling the fire service.
A report written by a fire investigator said the fire service were able to eliminate the television set, electrical outlets, the refrigerator and microwave as the origin.
"Although Mr Palmer was unable to state with certainty how the fire started on the balance of probabilities - which is the standard of proof I must apply - and based on common sense, I think the fire probably started as a result of Gavin smoking in bed. This was against the rules but was known to staff to be something that he did frequently."
The report concluded that the caregiver should not have been working on her own and she had panicked when she realised it was a fire and not a false alarm.
Mr Scott wrote that until Mr Hall died there had not been any fire drills at Kahu Kura, something that has now changed.
He also wrote that if sprinklers had been installed it would be "reasonable" to expect they would have activated and extinguished the fire in its early stages.
"Although I accept that there is no legal requirement to install sprinklers, I think that it is highly desirable in a complex of this nature that they are installed."
Mr Scott wrote that if it is not possible to install the sprinklers, for economic reasons, the trust should refuse to take residents who are smokers.
He recommended overnight staffing numbers increase to two.