Malcolm Campbell, 84, died after fire at bungalow where he lived alone

Malcolm Campbell died on 15 January 2023 at South Tyneside District General Hospital from the effects of smoke inhalation caused by a fire started by his own discarded smoking materials the previous day.  

Mr Campbell was in bed when the fire started and he managed to reach a chair in his lounge, where he was rescued by the fire service and then taken to hospital, but succumbed to the toxic effects of having breathed in carbon monoxide. 

At the inquest into Mr Campbell’s death at Gateshead and South Tyneside Coroners Court on Friday 12 June 2026, Assistant Coroner James Thompson concluded there were missed opportunities to assess Mr Campbell’s capacity or to seek his consent to explore decisions surrounding his place of residence and safety, which were possibly causative of his death. 

Due to frequent smoking in bed and increasing mobility issues, Mr Campbell had been assessed by the fire service as at high risk of harm from fire. As a result, his home was fitted with a monitored alarm, door sensors and other linked alarms.

In May 2022 Mr Campbell was diagnosed with dementia. Since November 2022, the coroner noted, he was seen to be declining in terms of frailty, mobility and cognitive ability. Those responsible for Mr Campbell’s care and welfare knew that he smoked in bed and engaged in other risky activities. 

In July 2022 an occupational therapist visit showed Mr Campbell had cognitive and functional difficulties, with the occupational therapist concerned about Mr Campbell’s ability to assess the risk of smoking or respond to a fire.  

In November 2022 Mr Campbell was classed by Tyne and Wear Fire and Rescue Service as not be able to self-rescue in five minutes and, the inquest had been told, Mr Campbell did not understand the risks which could cause a fire.  

In the month before his death, Mr Campbell was twice admitted to hospital, firstly after suffering a fall at home, and secondly after being found wandering by carers on the day of his discharge. Both times, the doctors who treated Mr Campbell assessed that he lacked capacity to decide on his care and treatment, and deprivation of liberty (DoL) authorisations were put in place. Mr Campbell’s family were not informed of any capacity assessments or DoLS. 

After each hospital admission Mr Campbell was sent back to his bungalow where carers visited him four times daily. 

The main concern for social services was Mr Campbell wandering rather than his fire risk, the coroner said. A tracking device was ordered for him but did not arrive before he was discharged. 
Mr Thompson said no assessment of Mr Campbell’s capacity was undertaken by social workers during their involvement with him during November 2022 until his death. He said there was an assumption of capacity throughout this period by them. 

The coroner observed that there were no arrangements in place to prevent a fire from starting at Mr Campbell’s bungalow and despite the reactive devices installed, the risk of fire was significant. He said it would have been a reasonable step to consider removing Mr Campbell from that environment. 

He said 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. 

Mr Thompson will issue a Prevention of Future Deaths report to the Secretary of State for Health and Social Care concerning; the lack of a mechanism for fire risk flags for patients of GP surgeries in the context of prescribing paraffin based emollient creams, the benefits of having a named social worker for continuity of care and recognition of a person’s deterioration, and reinforcing the need for professionals to be aware of the risks of returning someone to their home environment, rather than a sole focus on the ‘home first’ principle.  

He said there was evidence that since Mr Campbell’s death, the NHS Trust and the local authority have worked together to improve hospital discharge arrangements. 

Following the inquest, Mr Campbell’s granddaughter Marie Campbell, and his daughter, Sarah Desborough, 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. 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. Throughout this process, our focus has always been on seeking clarity and ensuring that his life, and the impact he had on those around him, was not forgotten. 

“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. His absence is felt every day, and he remains greatly missed by all who knew and loved him. 

“We would like to thank the coroner, our legal representatives, and everyone who has supported our family throughout this lengthy process. We are also grateful for the kindness, patience and understanding shown by our wider family, friends and community."  

Marie Campbell and Sarah Desborough were represented by Leanne Devine, human rights team partner at law firm Leigh Day.  

Leanne Devine 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.”