- Kirandip Bharaj died in a house fire in Blackpool in 2019
- She had a history of complex health needs including a complicated eating disorder
- An inquest found that an inadequate Mental Health Act assessment represented a ‘missed opportunity’ to hospitalise Kiran days before she died
The family of a woman who died in a house fire in Blackpool in 2019 have today said a ‘lack of accountability’ combined with a lack of understanding and training about eating disorders across the local NHS trust and the local authority had left her ‘at risk and vulnerable’.
With a history of complex mental health issues, including an eating disorder, Kirandip Bharaj (known as Kiran to her family), 45, had been under the care of both Mental Health Services at South Cumbria NHS Foundation Trust, and the community mental health team within Adult Social Care services from Blackpool Council, at the time of her death.
An investigation into the cause of the fire, which occurred on September 14th, later concluded that it had been started by a tea towel being placed on the hob, and that Kiran had accidentally turned on the hob instead of the oven. Kiran was visually impaired, profoundly deaf with multiple sensory issues and her family believe this is likely why she turned the wrong dial, coupled with her ongoing weakness from her self-starvation.
However, at an inquest which concluded last week at Blackpool and Fylde Coroner’s Court, where the family were represented by Aimee Brackfield of Simpson Millar, and supported by the charity INQUEST, evidence was heard of several care and service delivery problems relating to the care that Kiran had received in the weeks before she passed away.
This included a decision not to detain her under the Mental Health Act when her BMI had dropped to just 14, instead leaving her at her home despite concerns regarding her deteriorating health being raised by her GP and her family. The coroner described the decision not to take Kiran to hospital on 6th September 2019 as a ‘missed opportunity’, and described the Mental Health Act assessment that was taken to have been ‘inadequate’.
The coroner also heard that professionals in the Adult Social Care team had received no training specific to eating disorder issues, meaning they were ill equipped to pass accurate information to the specialists who were responsible for managing her treatment plan. This remains to be the case despite 4 years since Kiran’s death,
Further contradictory evidence was given about the chain of events leading up to Kiran’s death from 10th September 2019 onwards, with the Trust saying that they had told the Priory Group on Friday 13th September 2019 that she urgently needed an Eating Disorder bed, whereas the Priory Group claims they were told on 13th September that it was no longer needed.
Following Kiran’s 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.
The report detailed that Kiran had undergone two Mental Health Act assessments in the weeks before her death, both of which determined Kiran did not meet the threshold to be detained in hospital. An independent psychiatrist, instructed by the Coroner, gave evidence that he opined Kiran could have been detained on both occasions. The report also detailed that a specialist Eating Disorder bed was being sought for Kiran, 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.
Following the 1-week hearing, Senior Coroner Wilson delivered a short form conclusion of accidental death. The Coroner did also record on the Record of Inquest that certainly by 6th September 2019, when Kiran was assessed by two specialist doctors, for a Mental Health Act assessment, Kiran’s weight was declining.
The Coroner further stated that there was a failure to sufficiently assess the status of Kiran’s eating disorder during this assessment, and that the assessment was ‘inadequate’. The Coroner found that Kiran’s presentation at tat time justified a period of detention in a hospital setting, where her declining weight could have been stabilised, and went on to describe the decision not to detain her as a ‘missed opportunity’.
The Coroner also recorded that when social care professionals attended Kiran’s home on 10th September 2019 and weighed her, her weight had reduced further. He concluded that a decision was then taken to seek an inpatient, specialist eating disorder bed for Kiran.
However, he further found that professionals could, at that time, have convened an ‘immediate’ Mental Health Act assessment which may have led to her admission to a general acute, or medical, bed in hospital, rather than ‘waiting for the specialist eating disorder bed to materialise’.
The Coroner agreed with Kiran’s family, as stated at the time, that there was a ‘real and imminent risk to Kiran’s life’, and that required urgent action to be taken. This did not occur.
The family have since said that they believe that a lack of accountability, the ongoing refusal to engage them in decisions about the care that Kiran needed, and a lack of training, understanding and awareness around Eating Disorders contributed to her death. Further, there were serious concerns raised by the family that they had been left in the dark whilst Kiran deteriorated despite ongoing attempts to seek help for her.
The family do not feel that they were taken seriously.
They say that they are particularly concerned about Blackpool Council’s response to the tragedy after Kiran’s sister, Simran, received a letter in 2021 saying that they HAD NOT reviewed their involvement in Kiran’s case to review its practices in a bid to learn lessons, and that they would not do so until the inquest had concluded. This was a concern also shared by the Coroner.
Speaking on their behalf following the hearing their lawyer, Aimee Brackfield from Simpson Millar Solicitors, said they were ‘utterly heartbroken’ by the catalogue of failings in the care that had come to light during the inquest.
The family had also been left disappointed that it took a Coroner to direct the Council to take necessary steps to safeguard life in the future, but were encouraged to see the Trust has taken active steps to address resourcing and training issues and hopes this will be imbedded correctly and will be ongoing.
Aimee added that the family are now desperate for lessons to be learnt, particularly in relation to how the complex needs of people with eating disorders are managed by the various relevant authorities – including ensuring that all staff receive training on the Medical Emergencies and Eating Disorders guidance which references an over reliance by professionals on ‘GDPR’ issues, preventing them from speaking to families.
The family have been very concerned by such comments, as individual data rights should never prevent professionals seeking input from the family, and indeed the MARSIPAN and subsequent MEED guidance encourage that, which they feel only seeks to reinforce the need for bespoke and specialist and ongoing training.
“The need to avoid ‘tunnel vision’ but to take a holistic approach when considering the health of an individual is key, which has been reinforced by the Coroner.
“We are pleased that the Coroner will be sending a Prevention of Future Death Report to Blackpool Council, whom have not taken any steps to learn lessons from Kiran’s tragic death, over 4 years ago.
“Simran and her family are understandably heartbroken that so many opportunities to save Kiran’s life were missed because of a lack of training and a lack of responsibility and accountability between multiple state organisations, which ultimately left her extremely vulnerable and at serious risk of harm. The fact she died of a fire bears no reduction on the risk she was placed at.
“They are hopeful that both Blackpool Council will take immediate action to improve things for individuals moving forward, and that those learnings are shared more widely to prevent future tragedies. They are also hopeful parties such as the Trust will engage with them with family focussed training to staff so they can better understand for the families left in a similar position. However, it will never replace the life that has been unduly lost through lack of adequate management and decision making.”
"This is a truly tragic case, and the evidence that has come to light throughout the inquest with regards the care Kiran received shows that there is a desperate need for change – both in terms of the way that the relevant authorities interact and communicate in an interdisciplinary manner, and the way people with eating disorders are supported in the community- especially when they are complex."
Associate Public Law Solicitor, Simpson Millar
Caroline Finney, a caseworker at the charity INQUEST, added: “Kiran’s sister has had to fight for justice, spending hundreds of hours poring over medical records and correcting narratives in a case where legal aid wasn’t automatically available.
“The fact that Blackpool Council have not even conducted a review, never mind actually implementing learnings demonstrates the yet again the lack of institutional will to make changes. Organisations like the Priory and Blackpool Council shouldn’t be relying on bereaved families to ‘do the work’ at inquests, essentially operating a ‘wait and see’ approach to accountability.
"Kiran’s family sadly join a long line of families whose loved ones have died as a result of multi-agency failings and a lack of will to care for individuals in a holistic and collaborative way. Multiple individuals and institutions saw ‘red flags’ and yet nothing was done to help Kiran. It is clear that there must be national oversight of organisations and their actions following deaths so that these patterns aren’t repeated."
Case worker, Inquest
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