Mental health services ‘failed’ flat fire victim

A hoarder with a history of lighting barbecues in his flat who died when he became trapped as a fire broke out was let down by mental health services which had “lost sight” of his deteriorating condition.

Robert Crane’s history of serious mental illness was “downplayed” by agencies which failed to work together in the years leading up to the huge fire which swept through his cluttered flat in Carolina House tower block in Dove Street, Kingsdown, on September 6, 2014.

Crane, a former musician who suffered from bipolar disorder, died of smoke inhalation and was found in the bath, according to an inquest into his death which opened on Monday.

The fire is believed to have come from a metal dish Crane had been using to cook on and heat his home – often with liquid gas – since his electricity was cut off due to debts more than a year earlier.

An investigation by the Bristol Safeguarding Adults Board, submitted to the inquest, found that social services, the NHS, emergency services and the council showed a “lack of consistent joined up working” which meant Crane’s deteriorating health was not identified properly.

Crane had been known to mental health services since 1997 and had been admitted as a psychiatric patient eight times up until 2011.

After refusing to engage, he was discharged in 2012. Later that year he became an anti-social behaviour concern to police but his “long history of mental health issues [were] underestimated or discounted”.

Agencies lost sight of the fact that he had been detained under the Mental Health Act and was entitled to ongoing support, the report noted.

In 2013 residents began complaining of smoke coming from Crane’s balcony where it was thought he was lighting barbecues. He was also seen throwing things from his seventh floor flat. He was offered mental health reassessments, but failed to engage with social services.

In early 2014 further complaints were made about fires coming from his flat, and inspections revealed a cluttered and dirty apartment with records stacked to the ceiling. Complaints were also made that the rubbish chute was used for defecation.

Police took out an injunction in an attempt to prevent Crane from lighting fires in his flat, which was now deemed a health risk.

A visit on June 17 by Avon and Wiltshire Mental Health Partnership (AWP) found Crane in women’s clothes, walking with bare feet “ingrained with dirt [and with] long, curling toenails”.

A health visitor noted: “The flat was filthy and full of old rubbish, broken furniture and numerous electrical speakers that were piled high. The only access was to climb over a broken settee that blocked the door from opening fully.

“Flat full of flies and mess … more broken furniture and clothes outside. Evidence of charred and burnt furniture.”

Although Crane was found to be a “self neglect” risk, the assessor concluded “as there does not appear to be a role for mental health services and as Mr C is refusing to engage, [he] will be discharged.”

Further attempts by mental health services to make a “community assessment” were planned, but were not carried out before the fire which consumed the apartment and led to the evacuation of the 14-storey tower block in a plume of smoke that could be seen from across Bristol.

The Safeguarding Adults Board found Crane’s mental illness had been “downplayed” in the run-up to the fire. It said an “inconsistency of joint working” and “lack of leadership” by agencies had hindered better support and referrals for his condition.

It also noted that the council’s Adult Social Care services and AWP underwent “major restructure” between 2011-2013, moving towards an “emphasis on short-term problem solving”.

It added: “The current trend for agencies to adopt a ‘one-touch’ approach in dealing with requests for assessments, with a view to swift onward referral … needs to be critiqued in the light of the disjointedness and lack of follow-up that occurred in Mr C’s case.”

Louise Lawton, independent chair of the BSAB, said: “The findings of this review highlight a number of key things, particularly around how agencies recognise and deal with the complex issues of self-neglect and mental capacity.

“There are lessons for all agencies involved with Mr Crane and this review has generated important learning which will be disseminated accordingly.”

Mark Dean, AWP’s adult safeguarding lead, said: “We are committed to doing all we can to safeguard people in our care and we will be fully cooperating with the Coroner’s inquest.”

An inquest into Mr Crane’s death is expected to last until Friday.

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