An accidental death

In 2019, a 74-year-old woman was pronounced dead in her home after neighbours alerted emergency services to a potential fire. Investigations revealed that the fire had been caused when the deceased used a match to light a cigarette. She had used a paraffin based emollient cream, but the indication for its use was not mentioned in the coroner’s report. She was known to be a heavy smoker, and the paraffin based cream probably soaked her clothing, acting as an accelerant for the fire. One month before her death, her carers, who were concerned about the risk of fire, had made a safeguarding referral. However, no actions were taken to mitigate harms prior to her death. A low level of carboxyhaemoglobin was identified in the toxicology analysis, and burns were listed as the cause of death. The coroner concluded the inquest as an 'accidental death’.2

During the inquest, the coroner raised several concerns surrounding a lack of awareness of the fire risk of paraffin based creams by healthcare professionals, carers and the public (box 2). The coroner addressed these concerns to six organisations, including: the Department of Health and Social Care, the National Institute for Health and Care Excellence (NICE), Public Health England, the British Medical Association, the Care Quality Commission, and Trent and Dove Social Housing. To date (January 2021), three organisations have responded.

The Department of Health and Social Care responded on 21 January 2020 (due 17 January) and described previously seeking advice from the MHRA, which resulted in a drug safety update in December 20187 and an in-depth review by the Commission on Human Medicines (CHM). In its response, the department also noted that the review by the Commission on Human Medicines led to two meetings with stakeholders to design resources and methods for their distribution in the form of a toolkit, which was published in July 2020,11 alongside a press release about the new campaign.12 13 Despite various efforts to share information about the risks, fatalities from fires associated with emollients continue to occur.

Safe use of emollients

Emollients are not spontaneously flammable, and they should not be discontinued based on the fire risk alone. The dangers arise when emollients are absorbed in clothing, bandages, bedding or furniture, and are combined with an ignition source. People who use large volumes of emollients, apply products often and to large surface areas; those who smoke, and people exposed to open flames (eg, when smoking or cooking), are at the greatest risk of harm, which appears to be unrecognised in the community.

Successful burn prevention programmes have combined education, product design change and legislation to prevent harm.14 Product design change was instigated in 2018 when legislation was implemented requiring all paraffin containing emollients to display warning labels, and the 2020 MHRA campaign focused on education.7 In isolation, these measures may not be as effective in preventing harm. Therefore, it is important to implement a multi-pronged approach that educates the public and healthcare professionals, uses product design change in leaflets and warning labels, and critically appraises these methods to ensure evidence-based policy decisions are made going forward.

Current measures to prevent harms may be insufficient. Since this prevent future death report was issued by the coroner (November 2019), four further deaths involving emollients have occurred (figure 1). Other aspects to consider in the prevention of harms from emollient related fires should include ongoing education, targeting high risk groups and the provision of better evidence related to the fire risks posed by emollients, including effective methods of prevention. While the resources provided by MHRA are freely available, their success in raising awareness among the public has not been appraised. Although emollient products contain written information and safety warnings on labels, this may be insufficient as users may not read this information.15 In addition, the MHRA campaign does not focus on targeting those at high risk of emollient related fires.

It is necessary for high risk persons to be actively identified at the point of prescribing, dispensing or purchasing emollients. However, some groups at risk may require additional actions, such as referral to a ‘stop smoking’ service or a fire safety assessment. Relevant government agencies should consider intensifying their efforts to distribute information to patients and highlight the importance of this risk to healthcare providers, which may be lacking in healthcare settings. For this to be successful, a national approach should be considered that will cascade down to the local level. In a busy clinical environment, alerts and checklists with relevant questions to identify high risk patients should be considered. The National Pharmacy Association created such a checklist in 2008, but it is unclear how widespread its use is to date.16

Emollients are the first line treatment for many dermatological conditions, and their importance in managing these conditions should not be overshadowed by their risk of accelerating fires.17 It should also be noted that other paraffin containing products, such as some topical antibiotics, may pose a similar risk, and preventative measures should be considered while ensuring the continued safe use of these products. While efforts are being made to raise public awareness of such harms through the media,18–22 actions to prevent future deaths are needed. For informed consent to occur, patients must be made aware of the risks, and healthcare professionals recommending or prescribing emollients must ensure patients are provided with this information. The public should also be encouraged to report harms to the yellow card scheme to ensure accurate monitoring of suspected harms. To date, third party organisations concerned with dermatological conditions and burns have not played a major role in educating the public about the risks of emollient related fires. These organisations are experienced and well placed to spearhead a collaborative effort to raise awareness and prevent harms.