Malcolm Campbell

Dear Mr Thompson, Re: Regulation 28 Report to Prevent Future Deaths – Malcolm Campbell who died on 15th January 2023. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17th June 2026 concerning the death of Malcolm Campbell on 15th January 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Mr Campbell’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Mr Campbell’s care have been listened to and reflected upon. Your Report raises the following concerns:
1. NHS patient records do not have the ability to warn medical professionals where a person is seen to be at risk of injury/death due to fire.
2. A named social worker or other social care professional is not currently allocated for the duration of someone’s care. Without this named person there is a concern that changes in someone’s condition and presentation won’t be as easily identified.
3. The aim of the ‘Home First’ policy is that individuals should return to their home upon discharge, however, you were concerned that the risks of return are not actively considered when deciding whether they should return home as opposed to other options.
1. Patient records flagging risks due to fire NHS England recognises that limited information sharing between care settings can contribute to less effective continuity of care, particularly when patients are receiving support within and between organisations and the patient is suffering with dementia. When prescribing a Paraffin based emollient, there would be a warning label on the product and label “Caution: flammable. Keep your body away from fire or flames after you have been put on the medicine.”

[Page 2] The British National Formulary (BNF) guidance also notes that ‘Healthcare professionals should advise patients not to smoke or go near naked flames because clothing, bedding, dressing and other fabrics that have been in contact with an emollient or emollient-treated skin can rapidly ignite. Washing these materials at high temperature may reduce emollient build up but will not totally remove it.’ The MHRA issued a drug safety update in 2020 to raise awareness on the issue. In this case, alternative non-paraffin based emollients may have been considered. If a patient has been assessed by the fire service as a fire risk, the GP practice would be able to include this assessment in the patient’s GP record and use options such as the EMIS ‘Major alert’ message or add free text notes to the medication module to give prominence to a high fire risk assessment if this were considered appropriate. (EMIS is an electronic patient record system.) This patient, by virtue of their dementia and the associated memory impairment which would have had a substantial long-term impact on their day-to-day functioning, would be eligible for a ‘Reasonable Adjustments Flag’. The purpose of this flag would be to support the patient to receive/benefit from reasonably adjusted care when interacting with the health and care service and may be relevant in this case. The Reasonable Adjustment Flag was developed in the NHS Spine to enable health and care workers to record, share and view details of reasonable adjustments across the NHS, wherever the person is treated. The capability is now available on the National Care Records Service (NCRS). A Fast Healthcare Interoperability Resources (FHIR) software interface is available for API- based integration with local point-of-care applications thus enabling sharing of information. There is also the possibility of use of ‘Additional Information’ in the Summary Care Record (SCR), which could provide carers with additional information. In addition, details of long-term conditions, significant medical history, or specific communications needs, is now included by default for patients with an SCR, unless they have previously told the NHS that they did not want this information to be shared.
2. Use of a named social worker NHS England does not have responsibility for social workers as this falls under the remit of Local Government and the Department for Health and Social Care (DHSC). As your Report is also addressed to DHSC they will be best placed to respond to this concern.
3. Considering risks as part of the ‘Home First’ policy The Home First approach is intended to support people to recover in the least restrictive environment that is safe and appropriate for their individual needs. It is based on evidence that unnecessary time in hospital can lead to avoidable harm.

[Page 3] The national discharge guidance does not establish a presumption that every person should return to their own home regardless of their individual circumstances. Rather, it promotes a Discharge to Assess (D2A) model in which discharge home is the default pathway where this is safe and appropriate, with alternative pathways available for people whose needs cannot be safely met at home. This includes bed-based intermediate care, residential or nursing care where clinically indicated. On 7 July 2026, NHS England published updated Model Hospital Discharge Principles, which reinforce that:
• discharge is a clinical decision based on individual assessment rather than an administrative process;
• discharge planning should commence at the point of admission and involve multidisciplinary teams;
• discharge home or to the usual place of residence is the default where safe, with bed-based pathways used where needed;
• patients and carers should be actively involved in discharge planning; and
• decisions should be informed by clinical judgement, risk assessment and the individual's needs. Taken together, these principles make clear that discharge planning must remain person-centred and based on a holistic assessment of clinical needs, risks, functional ability, available support and the wishes of the individual and, where appropriate, their carer. The guidance does not prevent or discourage consideration of alternative discharge destinations where these are assessed to be the safest and most appropriate option. All available discharge pathways should be considered as part of this assessment, with the selected pathway reflecting the individual's circumstances, needs and level of risk. Regional Response North East and Yorkshire regional colleagues have corresponded with North East and North Cumbria Integrated Care Board (ICB) who have advised us of that the ICB recognises and understands the concern raised regarding the application of the ‘Home First’ principle within hospital discharge planning. The policy intention is to support people to return to their usual place of residence wherever it is safe and appropriate to do so; however this should not be interpreted as a presumption that home is always the safest or most suitable discharge destination. In line with the principles of safe, person-centred discharge, decisions should be informed by an individualised assessment of need, risk, capacity, support arrangements and the views of the person and, where appropriate, their family or representatives. Where risks associated with returning home are identified, these should be clearly considered, documented and considered alongside alternative discharge options, including short-term residential or nursing care, reablement, intermediate care or other appropriate placements. The ICB would support the view that discharge planning should demonstrative active consideration of all relevant options on an equal and proportionate basis, rather than

[Page 4] applying the ‘Home First’ approach in a way that limits consideration of alternatives. This includes ensuring that multidisciplinary discussions evidence how risks have been identified, mitigated and reviewed, and that the rationale for the final discharge decision is clearly recorded. The ICB acknowledges that while supporting a ‘Home First’ approach must be particularly carefully considered where there is evidence of cognitive impairment, fluctuating or impaired capacity, escalating care needs, environmental risk, fire risk, fall risk, or concerns regarding a person’s ability to summon help or self-rescue in an emergency. In these circumstances, discharge planning does not rely solely on the availability of care visits or equipment-based mitigations and includes a clear multidisciplinary risk assessment of whether and how the identified risks can be safely managed at home. Where significant risks remain despite proposed support arrangements, the ICB would expect discharge discussions to evidence that alternative options have been actively considered, including short-term placement, intermediate care, reablement, residential or nursing care, or further assessment outside the person’s usual home environment. This is not inconsistent with the ‘Home First’ principle, rather, it ensures that the principle is applied appropriately, proportionately and in accordance with safe, person- centred decision making. The ICB acknowledges that in cases involving dementia, deterioration, known fire- setting or smoking-related risks, inability to self-rescue, or repeated concerns from professionals and carers, there should be clear evidence of risk ownership, escalation routes, mental capacity consideration, best interests decision-making where required, and agreement across relevant partners regarding the safest discharge destination. This should include documentation of the rationale where discharge home is agreed, alongside the specific measures in place to mitigate identified risks and the arrangements for review is risks escalate. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Mr Campbell, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.