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Inquest Concludes into Death of Vulnerable Man With History Of Mental Illness And Lighting Fires

Family say Opportunities missed to help Robert Crane before his death following blaze at council-owned flat


A vulnerable man who had a history of hoarding and lighting fires was failed by Bristol authorities who missed opportunities to help him before his death following a blaze at his seventh floor council flat.

The result of a serious case review into the care received by Robert ‘Bob’ Crane, was released as Assistant Coroner Dr Peter Harrowing examined the circumstances of his death at a week-long inquest which concluded today.

For more than a year prior to his death on September 6, 2014, 61-year-old Bob Crane was known to be lighting fires and hoarding flammable items in his flat in Carolina House, Bristol.  Bob’s flat was described by witnesses to the inquest as “filthy” “full of rubbish”, containing “charred and burnt furniture” and a “large fire load”.

Following his father’s death Alex Crane instructed expert civil liberties lawyers at Irwin Mitchell to investigate the care his father received from Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) and Bristol Social Services.

The inquest, held at Avon Coroner’s Court in Flax Bourton, Somerset, heard that Bristol Safeguarding Adults Board (BSAB) launched a serious case review in the wake of Bob’s death.

In a report presented to the coroner, BSAB said he died because his mental health history was "overlooked" and his risky anti-social behaviour was not seen as a symptom of his psychiatric condition.

Dr Mynors-Wallis, a consultant psychiatrist instructed by the coroner told the court:

“Mr Crane’s decision to live in the unsafe cluttered environment in which he was unable to safely care for himself was based on a faulty understanding of the risks and benefits and was not simply an unwise decision”. 

Alex said: “My dad was a man living with a serious untreated mental illness, which was putting him and other people in profound danger.  He filled his flat with highly flammable items and lit regular fires. By the time of his death he had been without electricity for 68 weeks.  

“Sadly it was all but inevitable that my dad would die in a fire, and it is a miracle that no one else was killed. Social services and the mental health trust ignored and downplayed my dad’s medical history and failed to take responsibility for his care, choosing instead to see him as someone else’s problem. .

“My dad and I were very close.  I looked after him for my whole adult life until the strain became too much and I placed my trust in Bristol City Council and the Avon and Wiltshire Partnership to keep him safe. I now see that my trust was misplaced. 

“It has been very difficult for me to sit in court while witnesses from Bristol City Council and the Avon and Wiltshire Partnership defended the lack of care my dad received and painted a picture of him which was at odds with the loving but troubled person I knew.  Ultimately, my dad’s case illustrates the dangers of expecting underfunded, undertrained and understaffed public services to care for mentally ill people in the community.”  

Bob was diagnosed with bipolar disorder in 1985, and had been on a regular prescription of lithium to control the illness until 2012 when he stopped collecting his medication.

He was the subject of a number of referrals, including one made by the local authority to the Trust on August 22, 2014 which raised concern about his lighting of fires on the balcony on his a regular basis.

In the following six months Avon Fire and Rescue Service were called to the property no less than four times following reports of a fire, and raised concerns regarding the amounted of flammable hoarded items at the property. He was visited by a community psychiatric nurse in July 2014 and a social worker four days before his death on September 6, 2014.

Following a visit to Bob’s flat on 7 July 2014 a community psychiatric nurse wrote to him stating: “Your flat is very difficult to enter or exit and, once inside, it is not easy to move around.  As you have no electricity, you are using candles for lighting and to cook.  You have a large amount of clutter throughout the flat, much of it being highly flammable.  The amount of rubbish you have is attracting flies and is a major health hazard.  All this contributes to a risk both to yourself and others.”  

Following a visit to Bob’s flat by a social worker on 6 September 2014 his flat was described as: containing “a large amount of items covering most spaces making it obvious that in the event of an emergency such as a fire, he would most likely find it difficult to evacuate with ease or quickly” with “a lot of debris on the floor of the corridor making it impossible to be aware of what might be under foot” and as giving risk to concern “over what would happen should there be a fire at the flat”.

The safeguarding report found that AWP failed to recognise that his "risky and chaotic lifestyle" was a symptom of his underlying mental disorder, instead recording that his behaviour was in fact “down to choice, rather than a symptom of his condition.”

Expert Opinion
“Bob was a desperately vulnerable man who lived in highly dangerous conditions for more than a year prior to his death.

“It is a matter of serious concern that none of the statutory agencies involved in Bob’s case sufficiently understood the legal powers they had available to them to keep him and other people safe. It is now for Bristol City Council and the Avon Wilshire Partnership to learn the lessons arising from this inquest so that vulnerable people living in the community receive a suitable, and safe, level of care.”
Gus Silverman, Associate Solicitor

The full Review can be found here:

Bristol Safeguarding Adults Board

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