Family of Blackpool woman who died in house fire believe ‘lack of training around eating disorders’ left her at risk

Kirandip Bharaj, known to her family and friends as Kiran, had a history of complex mental health issues.

A fire report concluded that the blaze in September 2019 had been caused by a tea towel that had been placed on a lit hob.

Kiran was visually impaired and deaf, and her family believe this is likely why she turned the wrong dial, coupled with her ongoing weakness due to her eating disorder.

The 45-year-old was under the care of mental health services at Lancashire and South Cumbria NHS Foundation Trust at the time of her death.

She had also been receiving support from Blackpool Council’s community mental health team.

An inquest at Blackpool and Fylde Coroner’s Court last week, problems with the care Kiran had received in the weeks before she died were heard.

This included a decision not to detain her under the Mental Health Act when her BMI dropped to just 14.

The coroner described the decision not to hospitalise Kiran on September 6, 2019 as a “missed opportunity”, and described the Mental Health Act assessment she received as “inadequate”.

The coroner also heard that professionals in the adult social care team had received no training specific to eating disorder issues.

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.

The review 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 she did not meet the threshold to be detained in hospital.

An independent psychiatrist, instructed by the coroner, gave evidence that he believed 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.

Senior Coroner Wilson concluded Kiran’s death was accidental following the one-week hearing, but stated that there was a failure to sufficiently assess the status of Kiran’s eating disorder during the assessment on September 6.

It was found that Kiran’s weight could have been stabilised if she had been admitted to hospital.

The coroner also recorded that when social care professionals attended Kiran’s home on September 10, 2019, they sought a specialist eating disorder bed for her as her weight had reduced further.

However, he further found that professionals could have convened an ‘immediate’ Mental Health Act assessment which may have led to her being hospitalised, rather than “waiting for the specialist eating disorder bed to materialise”.

The coroner agreed with Kiran’s family that there was a “real and imminent risk to Kiran’s life” and that urgent action needed to be taken. This did not occur.

Following the conclusion of the inquest, Kiran’s said they believed a “lack of accountability” and a “lack of training, understanding and awareness around eating disorders” contributed to her death.

Speaking on their behalf, 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.

However, she said Kiran’s family were encouraged to see the trust had taken active steps to address resourcing and training issues and hoped this will be embedded correctly.

“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,” she said.

Karen Smith, Director of Adult Service, said: “Following the tragic accident in September 2019, Blackpool Council continues to offer its condolences to the family of the late Kirandip Bharaj and all those whom loved her dearly.

“We will undertake an internal review into the care and support provided to Kiran and take a lessons learned approach to improving practice and outcomes for Blackpool residents. We will focus on the training needs and resources that our staff need; working jointly with our partner agencies to support people with complex mental health and social care needs, their carers and families.

“In the meantime, whilst the Coroner was clear that the lack of specific eating disorder training did not contribute to Kiran’s accident, we intend to identify and implement relevant additional specific training for all staff in relation to eating disorders.

“We acknowledges the comments of the Coroner made at the conclusion of the Inquest and the concerns that he notes in his report. The Council will respond formally to the report in due course when it has had a chance to consider this in full.”