PFD report

Pauline McInroy ALLISON · Prevention of Future Deaths report

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Issued 3 Aug 2021•West Sussex

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
4

Of 2 recipients

Stated actions
7

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to refer patients using emollient creams to their local Fire & Rescue Service for advice and assistance
    Part of recurring concern: Failure to reliably identify and refer vulnerable people at risk of fire
  2. Insufficient provision of fire-risk information to patients, families and carers using emollient creams
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Action

    Share updated emollient fire-risk communications with care homes, carers, and domiciliary-care agencies through the local authority.

    Stated by NHS Brighton & Hove CCG and NHS East Sussex CCG and NHS West Sussex CCGStated plannedThe respondent said that this action was planned when they made their response on 12 August 2021.
  2. Action

    Reissue primary-care warnings, reinforce patient and carer advice, distribute the patient leaflet through community pharmacies, and encourage fire-service referrals for at-risk patients.

    Stated by NHS Brighton & Hove CCG and NHS East Sussex CCG and NHS West Sussex CCGStated plannedThe respondent said that this action was planned when they made their response on 12 August 2021.
  3. Action

    Shared emollient fire-risk information with Sussex fire-service counterparts and professionals and the public.

    Stated by NHS Brighton & Hove CCG and NHS East Sussex CCG and NHS West Sussex CCGStated completedThe respondent said that this action was complete when they made their response on 12 August 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    Communicating patient safety alerts to the medical profession falls outside the organisation’s established role and authority.

    Stated by The British Medical Association (BMAOutside remitThe respondent said that this matter was outside its role or authority.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to refer patients using emollient creams to their local Fire & Rescue Service for advice and assistance

Wider context from the report

“(1) Mrs Allison used emollient creams containing flammable ingredients. I heard evidence that these ingredients can build up on clothing and bedding. The effect of this build up is to make material ignite more easily and burn more quickly. In addition to this the presence of an air mattress (often used by those with limited mobility) can further facilitate the ignition and spread of a fire by introducing additional air to the fire if it melts or punctures. The West Sussex Fire & Rescue Service informed me that they are trying to improve awareness amongst families, care providers and GPs of the increased risk of fire posed by the use of these types of emollient creams especially by immobile persons who smoke. I am concerned that not enough is being done to ensure that these patients, their families, and carers are aware of the risks and to ensure that they are referred to their local Fire & Rescue Service for advice and assistance. ”

Is this part of a recurring concern?

Yes — Failure to reliably identify and refer vulnerable people at risk of fire.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient provision of fire-risk information to patients, families and carers using emollient creams

Wider context from the report

“(1) Mrs Allison used emollient creams containing flammable ingredients. I heard evidence that these ingredients can build up on clothing and bedding. The effect of this build up is to make material ignite more easily and burn more quickly. In addition to this the presence of an air mattress (often used by those with limited mobility) can further facilitate the ignition and spread of a fire by introducing additional air to the fire if it melts or punctures. The West Sussex Fire & Rescue Service informed me that they are trying to improve awareness amongst families, care providers and GPs of the increased risk of fire posed by the use of these types of emollient creams especially by immobile persons who smoke. I am concerned that not enough is being done to ensure that these patients, their families, and carers are aware of the risks and to ensure that they are referred to their local Fire & Rescue Service for advice and assistance. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Share updated emollient fire-risk communications with care homes, carers, and domiciliary-care agencies through the local authority.

Verbatim wording from the response

“For the CCG to work with the local authority to share the updates and latest communication with care homes and carers and with domiciliary care agencies to reinforce the message | 31 October 2021 | Via Care Home cell – Comms team”

Source location

2021-0269-Response-from-CCGs
Page 5 · response
Published 12 August 2021

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Reissue primary-care warnings, reinforce patient and carer advice, distribute the patient leaflet through community pharmacies, and encourage fire-service referrals for at-risk patients.

Verbatim wording from the response

“month'. Anonymised reference to this incident will be made to emphasise it was a local case and primary care to be reminded to advise patients who use these products not to smoke or go near naked flames, and warn about the easy ignition of clothing, bedding, dressings, and other fabric that have dried residue of an emollient product on them . In addition, within the newsletter, primary care will be encouraged to ask any at risk patients (i.e. known smokers or those on home oxygen) to talk to their local Fire and Rescue Service and seek advice and guidance to help minimise the risk when using emollients.”

Source location

2021-0269-Response-from-CCGs
Page 4 · response
Published 12 August 2021

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Shared emollient fire-risk information with Sussex fire-service counterparts and professionals and the public.

Verbatim wording from the response

“4.1 CCGs leads from Safeguarding have recently spoken to their equivalents in the fire service across Sussex and a great deal of information shared again with professionals and the public regarding the risks of emollient creams.”

Source location

2021-0269-Response-from-CCGs
Page 3 · response
Published 12 August 2021

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Agree a timetable for regularly reiterating emollient fire-risk messages to primary care and patients and sharing them with smoking-cessation public-health colleagues.

Verbatim wording from the response

“4.4 CCG Safeguarding and Communication leads will agree a timetable for the reiteration of this message with primary care and patients so it is highlighted and visible on a regular basis. This will also include sharing information on the risks of emollient creams with public health colleagues working in smoking cessation programmes.”

Source location

2021-0269-Response-from-CCGs
Page 4 · response
Published 12 August 2021

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Disseminated emollient fire-risk warnings and incorporated them into training resources for staff and the public.

Verbatim wording from the response

“3.1 Sussex CCGs take very seriously the increased risk of fire posed by the use of these types of emollient creams and have disseminated warnings about this in the past. In August 2019, for example, the then Coastal West Sussex CCG, which covered parts of West Sussex issued a warning to primary care via a newsletter on the risks of emollients and fire. This included that they advise “patients who use these products not to smoke or go near naked flames, and warn about the easy ignition of clothing, bedding, dressings, and other fabric that have dried residue of an emollient product on them”. The same article also recommended health care staff “must ensure patients and their carers understand the fire risk associated with the build-up of residue on clothing and bedding and can take action to minimise the risk”.”

Source location

2021-0269-Response-from-CCGs
Page 3 · response
Published 12 August 2021

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Communicating patient safety alerts to the medical profession falls outside the organisation’s established role and authority.

Verbatim wording from the response

“As detailed in Coroner’s Concerns, Mr Simpson states that patients, carers, families, care providers and GPs should be more aware of these risks – something the BMA fully agrees with. However, we don’t believe that the BMA is the right organisation to achieve the required outcome.”

Source location

2021-0269-Response-from-British-Medical-Association_Published
Page 1 · response
Published 12 August 2021

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Medical defence bodies could disseminate information through precautionary case studies concerning safety incidents.

Verbatim wording from the response

“You may also wish to contact NHS England /Improvement who are responsible for delivery of NHS services, to see if they can communicate this message to providers. This would include pharmacist advisors in the community as well as in hospitals. We would also suggest contacting the Royal College of General Practitioners, who train and educate general practitioners throughout their careers. The medical defence”

Source location

2021-0269-Response-from-British-Medical-Association_Published
Page 1 · response
Published 12 August 2021

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

NHS England and Improvement is responsible for NHS service delivery and should communicate the message to providers.

Verbatim wording from the response

“You may also wish to contact NHS England /Improvement who are responsible for delivery of NHS services, to see if they can communicate this message to providers. This would include pharmacist advisors in the community as well as in hospitals. We would also suggest contacting the Royal College of General Practitioners, who train and educate general practitioners throughout their careers. The medical defence”

Source location

2021-0269-Response-from-British-Medical-Association_Published
Page 1 · response
Published 12 August 2021

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The MHRA should disseminate the safety alert to health professionals.

Verbatim wording from the response

“It is established practice that safety alerts regarding medicines and devices are sent to all doctors via the MHRA, and clinicians are already aware to make note of these alerts. We would suggest contacting the MHRA to disseminate this important safety alert to health professionals.”

Source location

2021-0269-Response-from-British-Medical-Association_Published
Page 1 · response
Published 12 August 2021

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The Royal College of General Practitioners should communicate the risks through its training and education of general practitioners.

Verbatim wording from the response

“You may also wish to contact NHS England /Improvement who are responsible for delivery of NHS services, to see if they can communicate this message to providers. This would include pharmacist advisors in the community as well as in hospitals. We would also suggest contacting the Royal College of General Practitioners, who train and educate general practitioners throughout their careers. The medical defence”

Source location

2021-0269-Response-from-British-Medical-Association_Published
Page 1 · response
Published 12 August 2021

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Enable locums to access prescribing newsletters and register for MHRA Drug Safety Updates.

    Stated by NHS Brighton & Hove CCG and NHS East Sussex CCG and NHS West Sussex CCGStated plannedThe respondent said that this action was planned when they made their response on 12 August 2021.
  2. 2

    Review whether prescribing-system searches or alerts can identify smokers prescribed emollients.

    Stated by NHS Brighton & Hove CCG and NHS East Sussex CCG and NHS West Sussex CCGStated plannedThe respondent said that this action was planned when they made their response on 12 August 2021.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Established MHRA arrangements already disseminate medicine and device safety alerts to doctors, who are expected to note them.

    Stated by The British Medical Association (BMAExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Enable locums to access prescribing newsletters and register for MHRA Drug Safety Updates.

Verbatim wording from the response

“Sussex CCG leads will be looking in to how we ensure locums are covered also and communicate with them both the emollient newsletter article but also in the future, how we enable them to access future prescribing newsletters and register for the MHRA Drug Safety Updates.”

Source location

2021-0269-Response-from-CCGs
Page 3 · response
Published 12 August 2021

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review whether prescribing-system searches or alerts can identify smokers prescribed emollients.

Verbatim wording from the response

“To review if searches and/or alerts can be put on the prescribing system to alert GPs when they prescribe emollients where the patient is known to be a smoker. | 31 October 2021 | Medicine Management and Digital Team”

Source location

2021-0269-Response-from-CCGs
Page 5 · response
Published 12 August 2021

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Established MHRA arrangements already disseminate medicine and device safety alerts to doctors, who are expected to note them.

Verbatim wording from the response

“It is established practice that safety alerts regarding medicines and devices are sent to all doctors via the MHRA, and clinicians are already aware to make note of these alerts. We would suggest contacting the MHRA to disseminate this important safety alert to health professionals.”

Source location

2021-0269-Response-from-British-Medical-Association_Published
Page 1 · response
Published 12 August 2021

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026