When something goes wrong in health and social care, the people affected and staff often say, "I don’t want this to happen to anyone else." These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue - what happened, what CQC and the provider have done about it, and the steps you can take to avoid it happening in your service.
The unsafe use of emollient creams can result in serious or fatal injuries from fire.
When supporting people to use emollient creams, it’s important to be aware of the risks. You might use emollient creams to help manage dry skin conditions such as eczema or psoriasis.
Emollients are easily transferred from skin on to clothing and bedding. There may also be reactions between emollients and fibres of dressings, clothing and items such as towels used to carry out personal care.
When fabric with dried-on emollient comes into contact with a naked flame, the resulting fire burns quickly and intensely.
Scientific testing shows that fabric burns quicker and hotter when contaminated with emollients. These fabrics include clothing, towelling, bandages or bedding. The emollients tested include those that:
- contain paraffin
- do not contain paraffin, such as those made with natural oils
- contain other flammable constituents.
People should continue to use emollients but to avoid serious injury, it's important to avoid any naked flame.
Regular washing of fabrics does not totally remove the risk.
Issues notified to CQC
In May 2018, CQC was notified of a fire at a care home in Lancashire. Nine residents were evacuated and there were no injuries to staff or residents. The fire started in the laundry room after emollient creams reacted with cotton towels which caused them to become flammable.
The fire authority issued an enforcement notice requiring the provider to make sure risk assessments are updated to reflect the safe use and storage of emollients. The notice required the provider to take those steps by 29 June 2018.
What can you do to avoid this happening?
Unfortunately, this sort of incident is not uncommon and has caused fatalities. But you can do something to reduce the risk.
In 2008, the National Patient Safety Agency reported a fatal incident. A paraffin-based skin product was in contact with a person’s dressings and clothing. A naked flame ignited the clothing. The Medicines and Healthcare Products Regulatory Agency (MHRA) issued a safety alert in 2008. MHRA updated the alert in 2016 and again in 2018.
The 2018 alert extends the warnings about the risk of severe and fatal burns from emollients. This includes all paraffin-based emollients regardless of paraffin concentration. It also includes paraffin-free emollients. It reminded healthcare professionals to:
- advise people who are using emollient creams of the risks the creams may pose, and:
- not to smoke
- not to use naked flames
- not to go near anyone smoking or using naked flames.
- change people’s clothing and bedding regularly because emollients soak into fabric and can become a fire hazard - people need to be aware that washing does not remove the risk
- be aware that fabric such as bedding or bandages that have dried residue of an emollient on them will easily ignite and to report any fire incidents with emollients or other skin care products to MHRA’s Yellow Card Scheme.
In July 2020, MHRA updated its guidance. It advises people who use an emollient or skin cream to:
- avoid smoking
- change and wash clothes and bedding
- keep cream off furniture
- tell relatives and carers
- tell your healthcare professional.