James Rownsley
PFD Report
All Responded
Ref: 2025-0430
All 1 response received
· Deadline: 24 Oct 2025
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
24 Oct 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
1. The need for effective communication to partners and stakeholders responsible for either prescribing such emollients, or indeed caring for people in the community, of the dangers of using such creams particularly when in close proximity to flames or heat.
2. An apparent lack of awareness of the both professionals and the public regarding the extent of that risk.
3. I was also told that since 2020 there have been 50 deaths in England involving emollient creams but there was a significant discrepancy between the data held by fire services in terms of there being 50 deaths, and the data held by Medicines and Healthcare Products Regulatory agency only had a record of 15. Accordingly, the current system of reporting such data to this regulatory authority should be reviewed with consideration to making this more robust or if there is an absence of such a referral process, for one to be introduced and communicating any such reporting requirements to all fire services.
5. The risk seems to be heightened in situations where elderly persons or persons of lower income are using such methods to heat their homes to avoid the cost of putting central heating on of the entire property.
2. An apparent lack of awareness of the both professionals and the public regarding the extent of that risk.
3. I was also told that since 2020 there have been 50 deaths in England involving emollient creams but there was a significant discrepancy between the data held by fire services in terms of there being 50 deaths, and the data held by Medicines and Healthcare Products Regulatory agency only had a record of 15. Accordingly, the current system of reporting such data to this regulatory authority should be reviewed with consideration to making this more robust or if there is an absence of such a referral process, for one to be introduced and communicating any such reporting requirements to all fire services.
5. The risk seems to be heightened in situations where elderly persons or persons of lower income are using such methods to heat their homes to avoid the cost of putting central heating on of the entire property.
Responses
The NFCC highlights that it has already implemented numerous preventative measures including partnering with MHRA for the 'Know the Fire Risk' campaign (launched in 2020 and recently updated), developing national guidance for Fire and Rescue Services, and providing training materials and a factsheet on emollient risks. It also notes local services like South Yorkshire FRS have delivered partnership training using this guidance.
AI summary
View full response
Dear Ms Mundy, Thank you for raising the concerns in relation to the death of James William Rownsley on 20 February 2025. It is with great sadness that I read about the circumstances of his death. The National Fire Chiefs Council (NFCC) is committed to a culture of learning and improvement and seeks to support fire and rescue services (FRSs) to embed a learning culture. We actively track Prevention of Future Deaths Reports and share them with our members to ensure all opportunities to improve are taken. In your report you have identified NFCC as being an organisation that has the power to take action to prevent future deaths associated with emollient creams In response to the recommendations made, they highlight a risk that has been recognised nationally for some years, and NFCC has worked closely with national health and safety bodies to raise awareness and implement preventative measures. In 2016, the Medicines and Healthcare products Regulatory Agency (MHRA) issued its first Drug Safety Update regarding paraffin-based products with less than 50% content. This guidance was expanded in 2018 to include all paraffin concentrations and paraffin-free emollients, following evidence that residue on fabrics such as clothing, bedding, and dressings significantly increases flammability. In 2020, NFCC partnered with MHRA to launch the joint national campaign 'Know the Fire Risk', supported by a multi-agency stakeholder group including fire services, clinicians, and academics. This campaign remains active and has recently been enhanced with new training materials, including a video titled 'Reducing Risk: Information for Carers and Support Workers'. In 2025, the Care Quality Commission (CQC) and the Homecare Association issued updated guidance to health and care providers on the safe use of emollients. NFCC has also embedded emollient-related fire risk into the Person-Centred Home Fire Safety Framework, which underpins prevention activity across all UK fire and rescue services.
Registered office: National Fire Chiefs Council Limited, 71-75 Shelton Street, Covent Garden, London, United Kingdom, WC2H 9JQ. Registered in England as Limited Company No. 03677186. Registered in England as Charity No. 1074071. VAT Registration No. 902 1954 46
NFCC has undertaken the following actions to address emollient-related fire risks:
• Maintained a dedicated emollient workstream since 2017/18.
• Developed and distributed campaign toolkits for fire services, NHS partners, and care providers.
• Delivered a joint MHRA/NFCC media campaign in 2020.
• Embedded emollient fire risk into Home Fire Safety Visits.
• Continued engagement with MHRA, NHS, CQC, and the Homecare Association. In response to the specific concerns raised in your report, NFCC has worked with MHRA, NHS England, CQC, and the Homecare Association to ensure that health professionals are aware of emollient-related fire risks. A presentation was delivered at the National Association of Healthcare Fire Officers Conference in May 2019 to healthcare fire officers, and emollient safety information has been shared with the National Pharmacy Association to support awareness in pharmacy settings. Campaign materials were circulated to all UK fire and rescue services, including the Homecare Association in September 2025, with a recommendation to strengthen engagement with GPs, district nurses, and care providers. While awareness has improved, we recognise that further efforts are needed. NFCC is exploring opportunities to support fire and rescue services and De Montfort University in developing national or regional webinars. These would target a broad audience including pharmacists, pharmacy teams, health service prevention teams, GPs, community safety teams, and fire and rescue professionals, building on recent examples such as the Norfolk adult safeguarding intervention. To further strengthen awareness and reporting, NFCC proposes:
• Convening a data review group with MHRA and selected fire and rescue services by December 2025.
• Issuing national guidance to support consistent reporting.
• Supporting the rollout of the Fire and Rescue Data Platform (FaRDaP) with emollient- specific fields by September 2026. NFCC is aware that current Incident Recording System (IRS) categories have not allowed consistent documentation of fire deaths where emollient products are a contributory factor. Since 2018, our emollients workstream project group has worked to improve incident reporting. In September 2025, FaRDaP was launched to replace IRS, and will introduce a dedicated field for emollient-related incidents from April 2026. The system is expected to include guidance on MHRA Yellow Card reporting, subject to confirmation and with full implementation expected by September 2026. We are currently engaging with the Ministry of Housing, Communities and Local Government (MHCLG) regarding access to data submitted through FaRDaP. While no formal agreement has yet been reached, our objective is to secure timely and relevant data to support sector-wide analysis. At present, MHCLG has indicated that data sharing will be considered on a case-by-case basis, and any data provided may be subject to delays due to processing and publication timelines.
Registered office: National Fire Chiefs Council Limited, 71-75 Shelton Street, Covent Garden, London, United Kingdom, WC2H 9JQ. Registered in England as Limited Company No. 03677186. Registered in England as Charity No. 1074071. VAT Registration No. 902 1954 46
We continue to recognise the heightened risk in vulnerable households, particularly among elderly residents, low-income families, and those using alternative heating methods. NFCC has embedded emollient fire risk into the Person-Centred Home Fire Safety Framework, and we will ensure this risk is highlighted during winter preparedness campaigns for 2025/26. A full timeline of guidance, campaigns, publications, and communications is provided in Annex A. Annex B highlights how South Yorkshire fire and rescue service (SYFRS) has incorporated NFCC guidance into local partnership training sessions and awareness initiatives. The NFCC remains committed to supporting fire and rescue services in their prevention efforts and to working collaboratively with health and care partners to reduce the risk of future deaths. We will be sharing our response with the host fire and rescue service and the Care Quality Commission to reinforce the key learning and highlight the work undertaken to date. We would also welcome any support the Coroner may be able to provide in helping to disseminate these important messages across health and adult social care settings, where wider engagement will be essential to preventing similar incidents in the future.
Registered office: National Fire Chiefs Council Limited, 71-75 Shelton Street, Covent Garden, London, United Kingdom, WC2H 9JQ. Registered in England as Limited Company No. 03677186. Registered in England as Charity No. 1074071. VAT Registration No. 902 1954 46
NFCC has undertaken the following actions to address emollient-related fire risks:
• Maintained a dedicated emollient workstream since 2017/18.
• Developed and distributed campaign toolkits for fire services, NHS partners, and care providers.
• Delivered a joint MHRA/NFCC media campaign in 2020.
• Embedded emollient fire risk into Home Fire Safety Visits.
• Continued engagement with MHRA, NHS, CQC, and the Homecare Association. In response to the specific concerns raised in your report, NFCC has worked with MHRA, NHS England, CQC, and the Homecare Association to ensure that health professionals are aware of emollient-related fire risks. A presentation was delivered at the National Association of Healthcare Fire Officers Conference in May 2019 to healthcare fire officers, and emollient safety information has been shared with the National Pharmacy Association to support awareness in pharmacy settings. Campaign materials were circulated to all UK fire and rescue services, including the Homecare Association in September 2025, with a recommendation to strengthen engagement with GPs, district nurses, and care providers. While awareness has improved, we recognise that further efforts are needed. NFCC is exploring opportunities to support fire and rescue services and De Montfort University in developing national or regional webinars. These would target a broad audience including pharmacists, pharmacy teams, health service prevention teams, GPs, community safety teams, and fire and rescue professionals, building on recent examples such as the Norfolk adult safeguarding intervention. To further strengthen awareness and reporting, NFCC proposes:
• Convening a data review group with MHRA and selected fire and rescue services by December 2025.
• Issuing national guidance to support consistent reporting.
• Supporting the rollout of the Fire and Rescue Data Platform (FaRDaP) with emollient- specific fields by September 2026. NFCC is aware that current Incident Recording System (IRS) categories have not allowed consistent documentation of fire deaths where emollient products are a contributory factor. Since 2018, our emollients workstream project group has worked to improve incident reporting. In September 2025, FaRDaP was launched to replace IRS, and will introduce a dedicated field for emollient-related incidents from April 2026. The system is expected to include guidance on MHRA Yellow Card reporting, subject to confirmation and with full implementation expected by September 2026. We are currently engaging with the Ministry of Housing, Communities and Local Government (MHCLG) regarding access to data submitted through FaRDaP. While no formal agreement has yet been reached, our objective is to secure timely and relevant data to support sector-wide analysis. At present, MHCLG has indicated that data sharing will be considered on a case-by-case basis, and any data provided may be subject to delays due to processing and publication timelines.
Registered office: National Fire Chiefs Council Limited, 71-75 Shelton Street, Covent Garden, London, United Kingdom, WC2H 9JQ. Registered in England as Limited Company No. 03677186. Registered in England as Charity No. 1074071. VAT Registration No. 902 1954 46
We continue to recognise the heightened risk in vulnerable households, particularly among elderly residents, low-income families, and those using alternative heating methods. NFCC has embedded emollient fire risk into the Person-Centred Home Fire Safety Framework, and we will ensure this risk is highlighted during winter preparedness campaigns for 2025/26. A full timeline of guidance, campaigns, publications, and communications is provided in Annex A. Annex B highlights how South Yorkshire fire and rescue service (SYFRS) has incorporated NFCC guidance into local partnership training sessions and awareness initiatives. The NFCC remains committed to supporting fire and rescue services in their prevention efforts and to working collaboratively with health and care partners to reduce the risk of future deaths. We will be sharing our response with the host fire and rescue service and the Care Quality Commission to reinforce the key learning and highlight the work undertaken to date. We would also welcome any support the Coroner may be able to provide in helping to disseminate these important messages across health and adult social care settings, where wider engagement will be essential to preventing similar incidents in the future.
Report Sections
Investigation and Inquest
On 3 March 2025 I commenced an investigation into the death of James William Rownsley. The investigation concluded at the end of the inquest. My conclusion at inquest was: Cause of Death: 1a Severe Burns Conclusion: Accidental death . Circumstances: James William Rownsley died on 20 February 2025 from severe burns at his home address after his clothing ignited following contact with a gas fire in his home. The presence of emollient cream on his clothing was a significant factor in his death
Circumstances of the Death
Mr Rownsley was a gentleman born in 1935 with limited mobility, who used emollient creams for his skin condition. On the 20th February 2025 he had got up early and was in the habit of lighting his calor gas fire to warm the sitting room whilst the central heating heated up the house. On this date he switched the fire on and then sat close by on his sofa. Mr Rownsley had residue of emollient creams both on the clothing he was wearing and on the throw over his sofa. When Mr Rownsley lit the gas fire a flame caught his clothing and ignited the clothes he was wearing. Mr Rownsley did not realise this had occurred until he sat down on his sofa. When he realised he managed to get to his feet, but was unable to extinguish the flames and fell to the floor where he passed away from severe burns. I heard evidence from the fire investigator that the emollients present on his clothing were responsible for the clothing catching fire and also responsible for the intensity of the fire that would have very rapidly developed once fabric had been ignited.
also informed me that despite the efforts of his local Fire Service, South Yorkshire Fire & Rescue, to educate their partners about the dangers associated with the of use of emollients and them becoming absorbed in clothing and bedding (which cannot be removed by washing) and risk of ignition appear not to be fully appreciated by the partners with whom they deal such as General Practitioners, nurses and many others. The family also made it clear that members of the public are unaware of the dangers posed and have made their own efforts to educate the public.
also informed me that despite the efforts of his local Fire Service, South Yorkshire Fire & Rescue, to educate their partners about the dangers associated with the of use of emollients and them becoming absorbed in clothing and bedding (which cannot be removed by washing) and risk of ignition appear not to be fully appreciated by the partners with whom they deal such as General Practitioners, nurses and many others. The family also made it clear that members of the public are unaware of the dangers posed and have made their own efforts to educate the public.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.