Malcolm Campbell, an 84-year-old grandfather with dementia, died from smoke inhalation after a fire broke out at his South Shields bungalow, an inquest has heard. The coroner concluded that social workers missed opportunities to assess Mr Campbell's capacity, which may have contributed to his death.
Fire Incident and Rescue
On January 14, 2023, a fire started in Mr Campbell's bungalow while he was in bed. He managed to reach a chair in his lounge, where firefighters rescued him. Despite being taken to South Tyneside District General Hospital, he died the next day from carbon monoxide poisoning.
Missed Opportunities
Assistant coroner James Thompson, at Gateshead and South Tyneside Coroners Court on June 12, 2026, stated there were missed opportunities to assess Mr Campbell's capacity or seek consent regarding his residence. These failures were possibly causative of his death.
Mr Campbell had been assessed as high risk due to frequent smoking in bed and mobility issues. His home had a monitored alarm, door sensors, and linked alarms. He was diagnosed with dementia in May 2022 and declined in frailty, mobility, and cognition thereafter.
Previous Concerns
In July 2022, an occupational therapist noted cognitive and functional difficulties. By November 2022, the fire service classified him as unable to self-rescue within five minutes. He was hospitalized twice in the months before his death: once after a fall and once after wandering. Both times, doctors assessed he lacked capacity and placed deprivation of liberty (DoL) authorizations, but his family was not informed.
Social services focused on his wandering rather than fire risk. A tracking device was ordered but not delivered before his discharge. No capacity assessment was undertaken by social workers from November 2022 until his death.
Coroner's Findings
Mr Thompson noted no arrangements to prevent a fire, despite reactive devices. He said removing Mr Campbell from that environment would have been reasonable. Article 2 (right to life) was engaged as the state knew of a real and immediate risk.
The coroner will issue a Prevention of Future Deaths report to the Secretary of State for Health and Social Care, addressing fire risk flags for GP patients using paraffin-based creams, the need for named social workers, and the risks of returning patients home under the 'home first' principle.
Family Statement
Mr Campbell's granddaughter Marie Campbell and daughter Sarah Desborough attended the inquest. In a statement through solicitors Leigh Day, they said: "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. While no outcome can change what happened, we hope lessons will be learned so other families do not endure similar circumstances."
Council Response
A spokesperson for South Tyneside Council said: "This is a deeply tragic case. 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."
