An inquest will resume next week for Kirandip Bharaj, 45, who died in a house fire in Blackpool on September 14, 2019.
A fire report concluded that the blaze had been caused by a tea towel being placed on the hob.
The report added that due to her impaired vision, Kiran had accidentally turned on the hob instead of the oven.
At the time of her death Kiran had been under the care of both Mental Health Services and Adult Social Care.
She had a history of complex mental health issues and a diagnosis of anorexia nervosa.
Following her death, a review “to learn any lessons that might help to prevent any further incidents of this nature” was carried out by Lancashire and South Cumbria NHS Foundation Trust, in which it identified a number of care and service delivery problems relating to the care that Kiran had received.
This included previous discharge from Complex Care and Treatment Team (CTT) without multidisciplinary team (MDT) discussion, discharge from Eating Disorder Services (EDS), and inadequate planning of care following mental health act assessments.
The report also detailed that Kiran had undergone two Mental Health Act assessments in the weeks before her death, before adding that a specialist Eating Disorder bed was being sought for her, and that there were plans to undertake a further Mental Health Act assessment when this was available.
However, in the absence of a specialist Eating Disorder bed, it was determined that she could not be detained under the Mental Health Act and she remained at her home, with no additional care or support put in place.
The review published by the Trust in April 2021 went on to make a number of recommendations, including ensuring that EDS had robust plans in place to support service users and their families when the patient has been assessed as needing a specialist EDS bed, and where one is not immediately available.
A further recommendation was made to carry out a Trust wide audit of health and social needs assessments, and to develop an improved plan to address the audit findings.
A recommendation for a referral was also suggested to the Blackpool Safeguarding Adults Board for a Safeguarding adult Review to review the multi-agency care provided to Kiran.
Aimee Brackfield, a public law expert who is supporting Kiran’s family at the inquest, said: “Kiran died under the most tragic of circumstances having struggled for many years with her mental and physical health.
“Now, more than four years on, her family hopes that the inquest will help them to understand the circumstances leading up to her death, including the care that she received, whether it was appropriate for her to be residing in the community at the time of her death, and whether more could have been done to safeguard her.”