Pauline Allison

BMA House 
Tavistock Square 
London WC1H 9JP 

E WHardy@bma.org.uk  

HM Coroners Service, County of West Sussex 
Coroner’s Office, Centenary House 
Durrington Lane 
Worthing 
BN13 2PQ 

5 October 2021 

Sent via email 

Dear 

, 

RE: Inquest into the death of Pauline Mcinroy Allison 

The  British  Medical  Association  (BMA)  has  now  considered  the  formal  report  under  Regulation  28  to 
Prevent Future Deaths, following the investigation into the death of Pauline Mcinroy Allison by Mr Robert 
Simpson, Assistant Coroner, West Sussex Coroners Service.  

We would like to emphasise our shared concern outlined within the report that more should be done to 
ensure patients are aware of the risks associated with emollient creams. We commend the West Sussex 
Fire & Rescue Service for raising awareness among both healthcare professionals and at-risk persons.  

We are aware that the UK Government and the Medicines and Healthcare Products Regulatory Agency 
(MHRA) have worked with the Commission on Human Medicines to ensure that appropriate hazards are 
listed  on  relevant  product  containers,  and  accompanying  Patient  Information  Leaflets  provide  both 
warnings  and  information  regarding  minimising  risk.  However,  it  is  clear  following  Mr  Simpson’s 
investigation, more should be done so that these risks are better communicated.  

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.  

The BMA is a trade union and professional association made up voluntarily of members, and not all doctors 
are members of the BMA. The BMA has never had a role for communicating patient safety alerts to the 
medical profession. 

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. 

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 

Registered as a Company limited by Guarantee. Registered No. 8848 England. 
Registered office: BMA House, Tavistock Square, London, WC1H 9JP. 
Listed as a Trade Union under the Trade Union and Labour Relations Act 1974. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
  
 
 
 
 
 
 
 
 
 bodies – which include the MDU, MPS and MDDUS also provide members with precautionary case studies 
to learn from safety incidents who could also disseminate this information. 

Yours sincerely  

Chair of Council 

Chief Executive  

Page 2 of 2

NHS Brighton & Hove CCG, NHS East 
Sussex CCG, NHS West Sussex CCG: 

Response to the Assistant Coroner 
for West Sussex Coroners Service 
Regulation 28 report to prevent future 
deaths  

27 September 2021 

 1.  Introduction  

1.1 

1.2 

This report provides a response to the West Sussex Coroners, in respect of the 
Regulation 28 report issued to NHS Brighton & Hove CCG, NHS East Sussex CCG 
and NHS West Sussex CCG (the CCGs). This report relate to the death of Pauline 
McInroy ALLISON on 26/03/2021 as a result of significant burns sustained in a fire 
at her home. 

The CCGs have taken the opportunity, as part of this investigation, to review its 
broader preventable deaths messaging relating to inflammable products and identify 
any  learning  outside  the scope of    the Regulation 28 report. The CCGs are aware 
of the risks from emollient creams containing flammable ingredients and have 
published warnings on this in the past as will be referred to later in this report.  

2.  Background  and context 

2.1 

2.2 

2.3  

 On 12 August 2021 the CCGs received a Regulation 28 Report to Prevent Future 
Deaths from the West Sussex Coroner’s office. This related to the tragic case of an 
immobile West Sussex resident who suffered burns at her home and died at the 
Royal Sussex County Hospital, Brighton in March 2021.   

The cause of the fire had been smoking materials coming into contact with flammable 
materials on the bed- the deceased used emollient creams containing flammable 
ingredients. The Regulation 28 report states that the deceased had been largely 
bedbound since 2017 and was known to smoke in bed despite having been warned of the 
dangers of this.  

The Regulation 28 report cited West Sussex Fire & Rescue Service attempts 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. The report expressed concern 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 and that more 
action should be taken to prevent future deaths by the CCGs.  

3.  Sussex CCGs work around emollient use risks  

 
 
 
 
 
 
 
 
 
 
 
 
 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”. 

3.2 

3.3 

In 2016 an MHRA Drug Safety Update was issued on Paraffin-based skin emollients on 
dressings or clothing: fire risk. This is summarised in appendix 2 at the end of this 
document. The MHRA Drug Safety Updates are sent to all practices/GPs on a subscription 
basis. All practices should be receiving these reports as they are a focus for questions by 
the Care Quality Commission on inspection on how practices deal with these reports when 
they come in and keep a log of any actions undertaken. In West Sussex there would always 
be a section on the quarterly locality prescribing group meetings for the drug safety updates 
and also would be included in the newsletter if relevant to general practice. 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. 

Following a death related to the use of emollient creams in 2019 an updated safety notice 
was circulated across both health and social care sector. This remains current advice and 
has been included in training resources for staff and the public. The East Sussex Coroner 
issued a Regulation 28 notice which was shared appropriately also across East and West 
Sussex and both health and social care with the fire service delivering bespoke training to 
their staff. The Coroner also forwarded the response from the MRHA and the NHS National 
Director for Patient Safety, (referenced above). In addition the Institute of Fire Engineers 
wrote an article relating to the impact of emollient creams on fire – this has been shared 
widely across both sectors and the county. 

4.  New plans to address emollient use risks 

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. 

4.2 

Sussex CCGs will be re issuing in this September’s newsletter to primary care a warning 
around the use of emollients and fire risk. This will be highlighted as 'message of the 

 
 
 
  
 
 
 
 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. 

4.3  Warnings for patients and carers will be reinforced including through a visual patient 

information leaflet produced jointly by the MHRA and the National Fire Chiefs Council. The 
newsletter will also be sent to the Local Pharmaceutical Committee representative on the 
Sussex Health and Care Partnership APC for dissemination out to community pharmacy 
highlighting the patient information leaflet that can be given to relevant patients when 
emollients are dispensed 

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. 

4.5  Appendix 1 below is a short timeline and list of planned actions Sussex CCGs will progress 

to help mitigate further fire risks linked to usage of emollient products.   

5.  Summary 

5.1 

5.2 

In response to the request for information and assurance from Sussex CCGs around 
providing mitigation on the causes leading to the tragic death of Mrs Allison, the above 
report outlines how seriously Sussex NHS commissioners and primary care have taken the 
fire hazard risk to users of emollient products and especially smokers. The report outlines 
work undertaken prior to this particular incident occurring to reduce the risk posed to users 
of emollient products and involved collaborative working with primary care and the fire 
brigade.  

The report also sets out what actions we have taken or plan to take in light of the death of 
Mrs Allison including communication work with our primary care teams and also linking 
emollient users with their local fire brigade for further support and advice. We are confident 
these will help raise better awareness of the dangers of smoking and fire risks associated 
with emollient products with both users of these products as well as their carers. We will 
ensure this message is repeated in a timely way within primary care.  

 
 
 
 
 
 
 
 
 
 Appendix 1 

Actions planned /timeline 

Task 

Remind GPs and pharmacies to 
refer patients identified at 
increased risk to the fire service 
via the GP bulletin as well as 
the prescribing updates 
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.  
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 
To look in to how locums are 
given access to the prescribing 
newsletters and register for the 
MHRA Drug Safety Updates. 

Timeline for 
completion 
30 September 2021 

31 October 2021 

Identified CCG Lead 
Team 
Comms and 
Medicine 
management 

Medicine 
Management and 
Digital Team 

31 October 2021 

Via Care Home cell –
Comms team  

31 October 2021 

Medicine 
management 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Appendix 2 

1Drug Safety Update Latest advice for medicines users. The monthly newsletter from the 
Medicines and Healthcare products Regulatory Agency and its independent advisor the 
Commission on Human Medicines Volume 9, Issue 9, April 2016 

Paraffin-based skin emollients on dressings or clothing: fire risk  

Smoking or a naked flame could cause patients’ dressings or clothing to catch fire when being 
treated with paraffin-based emollient that is in contact with the dressing or clothing.  

Reminder for healthcare professionals:  

• Advise patients not to: smoke; use naked flames (or be near people who are smoking or using 
naked flames); or go near anything that may cause a fire while emollients are in contact with their 
medical dressings or clothing  

• Change patient clothing and bedding regularly—preferably daily—because emollients soak into 
fabric and can become a fire hazard  

• Incidents should be reported to NHS England’s Serious Incident Framework (includes Wales), 
Healthcare Improvement Scotland, or to the Health and Social Care Boards in Northern Ireland 
When patients are being treated with a paraffin-based emollient product that is covered by a 
dressing or clothing, there is a danger that smoking or using a naked flame could cause dressings 
or clothing to catch fire. We informed healthcare professionals of this risk in January 2008.  

Examples of paraffin-based emollients include:  

• white soft paraffin  

• white soft paraffin plus 50% liquid paraffin  

• emulsifying ointment  

The risk is greater when these preparations are applied to large areas of the body, or when 
dressings or clothing become soaked with emollient.  

We are aware of a recent fatal incident reported to the NHS England National Reporting and 
Learning System, in which a naked flame ignited emollient in contact with a patient’s dressings 
and clothing.  

Posters have previously been available from the National Patient Safety Agency, and may be a 
useful source of information for local use.  

1 Article citation: Drug Safety Update volume 9 issue 9 April 2016: 9