Malcolm Campbell
17 Jun 2026 · Coroner James Thompson · Gateshead & South Tyneside
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. paraffin-based emollient cream causing fire spread
“Mr [name redacted] 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 [name redacted] 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. lack of long-term named social worker allocation
“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. inadequate risk assessment of discharge destination
“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 [name redacted] 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.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“(4) Members of the public are able to purchase emollient creams across the counter but are not verbally made aware of the potential fire hazards of emollient cream containing a low level of paraffin.”
This report
“Mr [name redacted] 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.”
Closely relatedConfidence 0.85 · high
Earlier report
“Evidence given by fire investigators was that they are increasingly attending fires involving (mostly) the elderly where there is evidence of petrol based emollient cream in use.”
This report
“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.”