An 84-year-old man with dementia died after a fire broke out at his home, despite professionals knowing he regularly smoked in bed and was at high risk.
Malcolm Campbell, 84, died from smoke inhalation after firefighters rescued him from his burning home in Shaw Avenue, South Shields, on January 14, 2023.
A coroner has now warned that more people could die unless concerns about NHS fire-risk warnings, social-care oversight and decisions to send vulnerable patients home are addressed.
Mr Campbell was diagnosed with dementia in May 2022 and became increasingly frail in the months before his death.
He lived alone, received four carer visits a day and regularly smoked in bed. His carers, GP and other professionals were aware of the danger.
Portrait (Image: Supplied)
A fire service assessment in November 2022 classed him as a high fire risk and found he could not escape unaided within five minutes of a blaze starting.
Smoke, fire and fall alarms were installed and Mr Campbell was given fire-retardant bedding.
But after two hospital admissions in December 2022, staff sent him home both times.
A Prevention of Future Deaths report by Assistant Coroner James Thompson says Mr Campbell was judged unable to make decisions about his care during both December admissions.
The report says no capacity assessment was carried out while he was at home between November 2022 and his death, or when he was discharged.
By then, his dementia had worsened and he was increasingly frail and almost bedbound.
The fire was started by Mr Campbell’s own discarded smoking materials while he was in bed.
On January 14, a local-authority monitoring service detected alarms at his home and tried to speak to him. His confused replies triggered an emergency response.
Firefighters and other emergency workers rescued and resuscitated Mr Campbell before taking him to South Tyneside District General Hospital, where he died the following day.
The coroner heard that a paraffin-based emollient cream prescribed for Mr Campbell may have helped spread the fire.
A fire investigator said cream applied to Mr Campbell’s legs may have built up in his bedding and carpet. Cream in its container may also have helped spread the blaze.
The report said NHS records lacked a dedicated “Fire” flag to warn staff when patients faced a serious fire risk.
Family (Image: Supplied)
The coroner said staff had to identify the risk by reading records and joining up information, even though Mr Campbell’s GP knew warnings appeared when prescribing paraffin-based products.
In response, NHS England said alternative non-paraffin-based creams could have been considered.
It added that GPs could use electronic alerts or medication notes to highlight a high fire risk. Mr Campbell would also have qualified for a “Reasonable Adjustments Flag” because of his dementia and memory impairment.
The coroner also criticised the use of different social workers, saying their assessments appeared to be snapshots of Mr Campbell’s condition.
He said one named professional overseeing Mr Campbell over time could have spotted his decline and changing risks sooner.
The Department of Health and Social Care said named social workers were not mandatory but that “it is good practice which local authorities should aim to adopt according to people's needs and local service arrangements.”
The report questioned whether staff had properly weighed the risks of sending Mr Campbell home against alternatives such as a temporary care-home stay.
NHS England stressed that its “Home First” policy did not mean patients should automatically return home regardless of risk.
It added: “The national discharge guidance does not establish a presumption that every person should return to their own home regardless of their individual circumstances.”
It said discharge decisions should reflect each person’s needs, risks and available support, with alternatives considered when home care was unsafe.
The North East and North Cumbria Integrated Care Board said discharge plans should consider alternatives, especially for patients with dementia, rising care needs or serious fire risks who cannot escape unaided.
The coroner warned that more people could die unless action was taken.
Mr Campbell’s granddaughter Marie Campbell and daughter Sarah Desborough welcomed the coroner’s findings and expressed hope that lessons would be learned.
READ MORE:
- Tragedy as retired County Durham couple die in campervan blaze on holiday in France
- Darlington OAP who fell down stairs lay alone for hours after emergency button failed
- Coroner's warning after ambulance delay contributed to County Durham man's death
After the inquest they said: “Today marks the conclusion of a long and difficult chapter for our family following the inquest into the death of our beloved father, grandfather and friend.
“We welcome the coroner’s conclusion and are grateful for the care and thoroughness with which he has investigated the circumstances surrounding his death.
“We hope that lessons will be learned from what happened and that meaningful improvements will be made so that other families do not have to endure similar circumstances in the future.
“He was deeply loved by his family and friends, and it is his life, rather than the circumstances of his death, that we wish people to remember.”