Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0396, written 22 Nov 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Nov 2019 |
|---|---|
| Reference | 2019-0396 |
| Deceased | Maureen Milton |
| Coroner | Margaret Jones |
| Coroner area | Staffordshire (South) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
| | REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. RT HON MATT HANCOCK MP SECRETARY OF STATE FOR HEALTH AND SOCIAL CARE THE CHIEF EXECUTIVE — NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE . DUNCAN SELBIE, CHIEF EXECUTIVE PUBLIC HEALTH ENGLAND . THE CHIEF EXECUTIVE, BRITISH MEDICAL ASSOCIATION THE CHIEF EXECUTIVE, CARE QUALITY COMMISION _ THE MANAGER TRENT AND DOVE SOCIAL HOUSING N Oanhw CORONER | am Mrs Margaret Joy Jones assistant coroner for the coroner area of Staffordshire South. CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On 22.08.2019 | commenced an investigation into the death of MAUREEN MILTON AGED 74. The investigation concluded at the end of the inquest on 20.11.2019. The conclusion of the inquest was ACCIDENTAL DEATH, with the medical cause of death recorded as “1a Burns”. CIRCUMSTANCES OF THE DEATH The deceased was 74 years of age, she had poor mobility and was something‘of a recluse. She was known to be a very heavy smoker. Carers had identified that she was at risk of fire and consequently a safeguarding referral had been made in July 2019. On the 25"" July 2019 she refused to have her smoke alarm linked to her first call alarm. At 0911 hours on the 18" August 2019 Staffordshire Fire and Rescue were called to her flat in Burton upon Trent by neighbours. On arrival they were confronted with a smoke-filled property. The deceased was recovered from the lounge and pronounced dead at the scene. Fire investigations identified the source of the fire to be a cooks (long) match used to attempt to light a cigarette coming into contact with clothing (probably a nightdress) worn by the deceased whilst she sat in an armchair in the lounge of the property. There was evidence of petrol based emollient cream which she was likely to have used and which probably soaked her clothing. This would have acted as an accelerant to the fire. Toxicology identified 4 low level of carboxyhaemoglobin and the cause of death was burns. ‘ wy CORONER'S CONCERNS ores During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — 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. The petrol base is found in a significant number of prescribed creams and creams (such as moisturisers) which are readily available over the counter. This cream impregnates clothing and is not washed away during a normal washing programme. In the event of a fire the victim is rapidly engulfed by flames with little chance of survival. The cause of death is generally burns, not inhalation of smoke. The concern is the lack of awareness of this problem by medical professionals, carers, victims and their families. It is felt appropriate heighten awareness of this growing problem amongst health professionals and others who work in the field of prescribing such creams and those caring for patients using petrol based emollients. i ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action. ae YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 17.01.2020 I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (family member), a West Midland Fire Service, and Staffordshire Fire Service | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 22.11.2019 SIGNED BY CORONER ares Margaret J Jones M4, LHM Senior Coroner Staffordshire (South) Coroner’s Office No 1 Staffordshire Place Stafford ST16 2LP Tel No: 01785 276127 Fax No: 01785 276128 www.staffordshire.gov.uk sscor@staffordshire.gov.uk
3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
e From Nadine Dorries MP Pari tary Under Secretary of State for Mental Health, Department amen Sulide Prevention | and Patient Safety of Health & H 39 Victoria Street Social Care ‘ctor Siveet SW1H OEU Your Ref: AAH/RE152021 020 7270 4850 Our Ref: PFD-1197497 Mrs Margaret J Jones HM Assistant Coroner, Staffordshire (South) 1 Staffordshire Place Stafford ST16 2LP Daw Ms, Yes Thank you for your correspondence of 22 November 2019 to Matt Hancock about the death of Mrs Maureen Milton. | am replying as Minister with responsibility for patient safety. 2 | 5& January 2020 Firstly, | would like to say how saddened | was to read of the tragic circumstances of Mrs Milton's death. | offer my sincere condolences to Mrs Milton’s family and loved ones. In preparing the response to your report, Departmental officials have taken advice from the Medicines and Healthcare products Regulatory Authority (MHRA) which is an executive agency of the Department of Health and Social Care and is responsible for ensuring that medicines and medical devices available in the UK meet applicable standards of safety, quality and efficacy. The matters of concern in your report are that there is a lack of awareness among healthcare professionals, patients and their carers, of the fire risk associated with the use of paraffin-based emollient creams; and that paraffin is found in a number of prescribed creams as well as creams such as moisturisers that are readily available over the counter. The MHRA advises that it most recently communicated information about the risk of severe and fatal burns with paraffin-containing and paraffin-free emollients in December 2018 through a press release and an article in Drug Safety Update’. These communications resulted from an in-depth review of this issue by the MHRA’s independent expert advisory committee, the Commission on Human Medicines (CHM). Following that review, the MHRA has convened a stakeholder group that includes representatives from the fire service, healthcare professionals and their representative bodies, organisations that provide guidance to health and social care workers, patient representatives and organisations that speak for relevant patient populations such as the National Eczema Society. The stakeholder group is designing and optimising sustainable training and educational resources for healthcare professionals and the public and their method of distribution and access, to ensure these are impactful and maintain long-term awareness of the risk of emollient creams. | am advised that the group has met twice, most recently on 10 December 2019, and is working towards producing a toolkit of resources for patients, their carers’, healthcare professionals, health organisations and healthcare professional educators. The Government welcomes pians by the MHRA to officially launch the toolkit in 2020. This will be accompanied by a MHRA press release and stakeholders will propagate the key messages through their networks at the same time. | hope this reply is helpful. Thank you for bringing these concerns to my attention. Ved NADINE DORRIES
N | C National institute for 10 Spring Gardens Health and Care Excellence London SWI1A 2BU United Kingdom +44 (0)300 323 0140 9 December 2019 Mrs Margaret Joy Jones HM Assistant Coroner Staffordshire South Coroner’s Office No 1 Staffordshire Place Stafford S$T16 2LP HM CORONER'S OFFICE STAFFORDSHIRE SOUTH 1 1 DEC 201 Our ref: EH-303143 Dear Mrs Jones, | write in response to your correspondence, dated 22 November 2019, regarding the tragic death of Maureen Milton. We have considered the circumstances surrounding Ms Milton’s death, and the concerns raised in your report — that there needs to be heightened awareness amongst health professionals, patients and carers about petro!-based emollients being flammable. We do not consider that tnere is any action required from NICE on this issue. NICE does not have a role in overseeing the safety of medicines and medical products, or in ensuring appropriate warnings on the labels of such products. In the UK, this Is the responsibility of the Medicines and Healthcare products Regulatory Agency (MHRA). In addition, NICE does not have a role in running safety awareness or educational campaigns aimed at professionals or patients and carers. The responsibility for this would rest with organisations such as the MHRA and other healthcare regulators, professional bodies and voluntary organisations and charities. Prescribers are expected to refer to a medicine's clinical and safety information to help inform prescribing decisions made with patients. This includes being familiar with guidance within the British National Formulary (BNF). This expectation is set out in the General Medical Council's publication on ‘Good practice in prescribing and managing medicines and devices’, within the section titled: Keeping up to date and prescribing safely. The British National Formulary (BNF) provides prescribers and other healthcare professionais with information about the appropriate selection, prescribing, administration and monitoring of medicines. The BNF is a joint publication of the British Medical Association and the Royal Pharmaceutical Society. It is accessible from the NICE website. The BNF contains information on emollient and barrier preparations which includes advice from the www.nice.org.uk | nice@nice.org.uk MHRA/Commission on Human Medicines (CHM) (dated December 2018) warning about the risk of severe and fatal burns with paraffin-containing and paraffin-free emollients. The BNF also contains cautionary and advisory labels regarding individual emollient products that warn, for example, where such products are flammable. It's not clear whether Ms Milton was using an emollient for dry skin or a specific health condition such as eczema. The NICE website features clinical knowledge summaries (CKS) which are concise summaries of current evidence and best practice for primary care professionals, such as GPs. The CKS advice on eczema — atopic includes the following information: “People who need to use large quantities (more than 100 g) of any paraffin- based product should regularly change clothing, bedding, or dressings which become impregnated with the product and keep away from naked flames, as there is a risk of fire [ABPI, 2016a]”. We consider that appropriate information and warnings are available to prescribers regarding the risks of fire associated with the use of paraffin-based emollient products, and that there is nothing specifically NICE can do to add to this. As explained above, an awareness or educational campaign for professionals, patients or carers on this important issue would not fall within our role. Yours sincerely, -~ Sir Andrew Dillon Chief Executive
Public Health England Protecting and improving the nation’s health Public Accountability Unit Tel: 020 8327 6920 Wellington House 133-155 Waterloo Road www.gov.uk/phe London SE1 8UG By email and recorded delivery sscor@staffordshire.gov.uk Our ref: 28/11/ab/911 7 January 2020 Dear Ms Jones Re: Coroners Investigation Thank you for sending the attached report for PHE’s consideration. Under the Coroners and Justice Act 2009 please find below Public Health England's response in relation to the investigation of the death of Maureen Milton. We have reviewed the report and Public Health England have no comments to add as the report refers to the risks of petroleum-based emollients/skin creams which have been implicated in fire deaths prescribed to the elderly, as they act as an additional fuel. As the skin creams are medicines, the Medical and Healthcare products Regulatory Agency (MHRA) would be better placed to respond on this occasion. Please do not hesitate to contact PHE should we be of any further assistance in this matter. Yo ert
See every Prevention of Future Deaths report matching Margaret Jones, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.