Safeguarding Review Says Opportunities Missed To Help Robert Crane Before His Death Following Blaze At Council-Owned Flat

The Avon and Wiltshire Mental Health NHS Partnership Trust has paid damages to the family of a man with bipolar disorder who died in a fire at his seventh floor council flat. 

For more than a year prior to his death on September 6, 2014, 61-year-old Robert ‘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 an inquest into his death as “filthy” “full of rubbish”, containing “charred and burnt furniture” and a “large fire load”.  He lived without electricity for 68 weeks prior to his death and lit fires to cook with and see by.

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.

Bristol Safeguarding Adults Board (BSAB) launched a serious case review in the wake of Mr Crane’s death and concluded:

• Mr Crane’s mental health history was “overlooked” and his risky behaviour was not seen as a symptom of his psychiatric condition.
• There was “no evidence of overall analysis or planning to inform a shared strategic approach.  Each episode or incident tended to be viewed in isolation and not in context, either of [Mr Crane’s] previous history, or of other agencies’ experience of him.”
• “… no agency took the lead in developing an overall risk mitigation or management plan …”
• There was “no evidence that there was any guidance for staff or systematic approach to working out what might be the best way of working with someone who did not engage with services”

The report identified six “missed opportunities” and made six separate recommendations for change.

At an inquest into Bob’s death in October 2016, an independent consultant psychiatrist, Dr Mynors-Wallis, 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 Crane 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.

“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 amount 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 the Trust has 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.”

In July 2017, it was announced that Bristol City Council would be subject to an independent review after Bijan Ebrahimi, a disabled refugee was murdered in Bristol after a seven-year hate campaign by neighbours.

Gus Silverman, is an expert civil liberties lawyer at Irwin Mitchell, who represented Alex Crane.

Expert Opinion

“It’s extremely concerning that Bob was allowed to continue living on the seventh floor of a high rise block when the authorities knew that he was regularly lighting fires, living without electricity and suffering from a serious untreated mental illness.

“It is particularly concerning 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 the other residents of Carolina House safe.

“It is now incumbent on Bristol City Council and the Avon and Wiltshire Mental Health Partnership NHS Trust to demonstrate that they have changed their practices and procedures following this shocking case.” Gus Silverman - Associate Solicitor