“Mr Campbell was prescribed an emollient cream which carers would apply to his legs”

The coroner’s concerns

1. Mr Campbell was prescribed an emollient cream which carers would apply to his legs. This cream had a paraffin base. A fire investigator opines the cream may have over time soaked into bedding and the carpet near his bed as, well as its presence in its container, once the fire started allowed the fire to spread. Mr Campbell’s GP was aware when prescribers select an item which contains a product with paraffin in it an warning is displayed. However, there was no ability to place on a patient’s medical records a ‘Fire’ flag to show that person has been classed as a fire risk due to smoking in bed etc. The medical professional would need to read the patient’s medical records to identify any fire risk issues and make the connection between this and the potential risk of issuing a paraffin based product. I have a concern that NHS patient records do not have the ability to overtly warn medical professionals where a person is seen to be a risk of injury/death due to fire to assist them in tasks such a prescribing medication, home visits etc. This appears to be a concern which is not confined to a individual surgery, but to medical records systems generally. 2. Mr Campbell was seen by different social workers on several occasions during the last few months of his life. There was evidence that they and other professionals saw him for a limited period of time and their assessments were based on a ‘snap shot’ of his presentation at that particular time. Evidence was heard that the use of a named social worker or other social care professional who could be allocated to a person for the duration of their care. This could enable better monitoring of a service user and to enable better intelligence to be gathered to allow better decision making. The inability to undertake this allocation of named social work professionals was seen as due to the significant increase in workload since the Covid pandemic. My concern is the allocation of a social worker or equivalent who can ‘supervise’ a service user over a long period may be more adept at identifying changes in their condition and presentation. 3. Social workers gave evidence about the strategy of Improving Hospital Discharge (https://www.england.nhs.uk/urgent-emergency-care/improving-hospitaldischarge/reducing-long-term-stays/) which contains the principle (5) of ‘Home First’. The expectation that upon discharge from hospitals most persons should return to their home. I was told that the management of risk is paramount in that assessment of them returning home. However, I have heard evidence that other options such as Mr Campbell going to a residential/nursing home on a trial basis on discharge were not considered on an equal footing as the option of returning home. My concern is whilst the aim of the policy is understandable, those involved in the discharge process should actively consider the risk of a return to their home and consider other options on equal basis as a return home. 11. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: 1. The Family of Mr Malcolm Campbell 2. South Tyneside Council 3. South Tyneside & Sunderland NHS Foundation Trust 4. Cumbria, Northumberland and Tyne & Wear NHS Foundation Trust 5. Dale Care Limited I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12. SIGNATURE

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0400

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14 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0