Coroner’s report after South Tyneside fire which killed man

Malcolm Campbell, 84, died on January 15, 2023, at South Tyneside District General Hospital after inhaling smoke during a fire at his bungalow in South Shields the previous day.

Dementia, limited mobility, and hazardous behaviours such as smoking in bed had placed him at high risk, the inquest heard.

At Gateshead and South Tyneside Coroners Court on June 12, Assistant Coroner James Thompson concluded that South Tyneside social workers had missed “opportunities to assess Mr Campbell’s capacity” or seek his consent regarding where he lived or his safety.

Malcolm Campbell with his granddaughter Marie Campbell, bottom left, and daughter Sarah Desborough, right (Image: Supplied)

Mr Thompson said: “which were possibly causative of his death.”

Mr Campbell was rescued by firefighters but later died from the effects of carbon monoxide inhalation.

The fire had started from “his own discarded smoking materials” while he was in bed.

He managed to reach a chair in his lounge, where he was rescued by the fire service.

The bungalow had been fitted with a monitored alarm, door sensors, and other linked alarms to support his safety due to his frequent smoking in bed and growing mobility issues.

Malcolm Campbell (Image: Supplied)

He had been diagnosed with dementia in May 2022 and had been declining in terms of frailty, mobility and cognitive ability since November 2022.

An occupational therapist visiting in July 2022 raised concerns about Mr Campbell’s cognitive and functional ability.

The therapist questioned his understanding of the risks associated with smoking and his capacity to respond in an emergency.

By November 2022, Tyne and Wear Fire and Rescue Service had classified him as unable to self-rescue within five minutes of a fire starting.

They said Mr Campbell did not grasp the risks that could lead to a fire.

In the month before his death, he was admitted to hospital twice—once after a fall and again after being found wandering by carers.

On both occasions, hospital staff concluded he lacked capacity to decide on his care. Deprivation of Liberty (DoLS) authorisations were put in place, and Mr Campbell’s family were not informed of any capacity assessments or DoLS.

After both admissions, Mr Campbell was discharged back to his bungalow.

Carers visited him four times each day.

The coroner said social services considered his wandering a greater concern than his fire risk.

A tracking device was ordered but had not arrived before he was discharged.

Mr Thompson said no assessment of Mr Campbell’s capacity was undertaken by social workers during their involvement with him from November 2022 until his death.

The coroner found no measures had been put in place to prevent a fire in his home, and the reactive systems installed were not enough to mitigate the danger.

He said: “It would have been reasonable to consider removing Mr Campbell from that environment.”

Mr Thompson ruled that Article 2—the right to life—was engaged.

He said the state was aware of a real and immediate risk to Mr Campbell and was reasonably expected to take steps to protect his life.

He confirmed he would issue a Prevention of Future Deaths report to the Secretary of State for Health and Social Care.

He said: “There is evidence that since Mr Campbell’s death, the NHS Trust and the local authority have worked together to improve hospital discharge arrangements.”

Mr Campbell’s granddaughter Marie Campbell, and daughter Sarah Desborough, welcomed the coroner’s findings and expressed hope that lessons would be learned.

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.”

The family was represented by Leanne Devine of Leigh Day.

She said: “It is now on record that the state failed in its operational duty under Article 2 of the Human Rights Act to take reasonable steps to protect Malcolm’s life.

“This is a relief to Malcolm’s family, as is the Prevention of Future Deaths report that the coroner has said he will make.”

South Tyneside Council has been contacted for a comment.