"Deeply loved" - Coroner reveals 'missed opportunities' in care of South Shields grandad who died after blaze
The family of a South Shields pensioner who died after a fire at the bungalow where he lived alone say they finally have answers following an inquest into his death.
A coroner has found there were missed opportunities in the care of a South Shields pensioner who died after a fire at the bungalow where he lived alone.
Malcolm Campbell, 84, was twice assessed by hospital doctors as lacking the capacity to decide his own care in the month before his death on January 15, 2023.
The previous evening, the retired taxi firm owner was rescued from a blaze at his council bungalow in Shaw Avenue, Whiteleas.
He succumbed to the toxic effects of breathing in carbon monoxide in hospital the next day.
His inquest at Gateshead and South Tyneside Coroners Court was told he was seen by doctors after a fall at his home and then after being found wandering hours later.
It led to a court-sanctioned Deprivation of Liberty authorisation being put in place for others to safeguard his wellbeing.
Despite that, Mr Campbell, who was known to smoke in bed, was discharged both times alone to his home, with social workers visiting him four times a day.
The inquest heard they made an assumption of capacity and no further assessment around that was done during their involvement with him from November 2022.
Assistant Coroner James Thompson said their main concern was his wandering rather than his fire risk.
He added there were no arrangements in place to prevent a fire from starting and despite the reactive devices installed, the risk of a blaze was significant.
Mr Thompson said it would have been a reasonable step to consider removing Mr Campbell from that environment.
He found there were missed opportunities to assess his capacity or to seek his consent to explore decisions surrounding his place of residence and safety.
Both were possibly causative of Mr Campbell’s death, he said at the conclusion of the inquest.
The coroner ruled Article 2, the right to life, was engaged as 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 has now issued a Prevention of Future Deaths report to the Secretary of State for Health and Social Care.
It contains his concerns around the benefits of having a named social worker for continuity of care and recognition of a person’s deterioration.
And it calls for reinforcement of professionals’ awareness of the risks of returning someone to their home environment, rather than a sole focus on the ‘home first’ principle.
In response, Dr Shaz Wahid, Executive Medical Director at South Tyneside and Sunderland NHS Foundation Trust, said: “We continue to work closely with our local authority partners to strengthen arrangements for patients leaving hospital.
“This includes improving the support available to patients and their families at the point of discharge and further developing our joint working with social care teams and care providers to support a safe and well-coordinated return home.”
A spokesperson for South Tyneside Council, which is responsible for social services, said: “We will carefully consider the coroner’s findings and continue to learn from them.
“Adult Social Care has already undertaken an extensive review and introduced improvements, including measures to better manage risk.”
‘We hope lessons can be learned’
The family of Malcolm Campbell described the conclusion of the inquest into his death as being the end “a long and difficult chapter”.
In a joint statement, his daughter, Sarah Desborough, 40, and granddaughter Marie Campbell, 27, said: “For more than three and a half years, we have lived with the pain of his loss while waiting for answers.
“The inquest process has been emotionally challenging, but it has provided us with a greater understanding of what happened, which has been important for our family.
“While no outcome can change what happened or bring him back to us, we are thankful to now have a greater understanding of 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.”
Leanne Devine, human rights team partner at law firm Leigh Day, which represented the family, said: “Malcolm Campbell died after South Tyneside social services lost sight of the need to be fully aware of his capacity to live alone in his bungalow.
“Everyone involved in Malcolm’s care knew that as a heavy smoker, he was at great risk of fire breaking out. His carers knew he was increasingly frail with a dementia diagnosis.
“And yet, even after doctors noted that Malcolm lacked capacity and a Deprivation of Liberty order was agreed, still he was sent back home to live alone with only four visits a day from carers.
“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.”