Important lessons to learn for all social care providers.

The following is from a Coroner Accidental Death Review on the 10-05-2016

In a recent case, the Coroner recorded a verdict of accidental death. The deceased had a terminal illness and was bedbound, and was primarily being cared for by his friend, as well as having carers coming into the home. The carers were responsible for assisting with activities of daily living, including applying E45 to the skin daily after his wash. E45 had been prescribed by his GP at the request of the district nurses. The deceased was smoking in bed when a fire caught hold, and despite efforts by his friend, as well as the fire crew (who arrived expediently) he was pronounced dead when taken to the Leicester Royal Infirmary.

Following an investigation, the Fire Officer felt that the most likely source of the fire would have been the deceased’s lighter, coupled with the fact that his bedding and clothing were covered in E45 emollient residue, which would have increased the fuel load and acted as an accelerant, increasing the intensity and speed with which the fire took hold. This alert is being circulated in order to reduce the risk of future deaths in similar circumstances.

Key points for action and learning:

  • E 45 is a paraffin-based product that is highly flammable
  • E 45 is widely available over the counter, as well as by prescription
  • The flammability of E45 and its potential for ignition is high (and not displayed on the packaging)
  • E 45 is used by a range of individuals, including adults, vulnerable persons, the elderly and children
  • All doctors and other healthcare staff involved in the care of patients should be mindful of the above and remind their patients of the highly flammable nature of E45, as well as its residue
  • Carers should not leave residue of E 45 on patient’s clothing or on their bed clothes as this can act as a fuel load in the event of a fire accident
  • E45 and its residue should never be placed near an open flame, including lighted cigarettes and other smoking equipment