A woman with learning difficulties who was pulled from her burning flat by firefighters did not have an appropriate care plan in place, an inquest into her death heard on Thursday (13th May).
58-year-old Suzette Osborne died in a burns unit in Swansea on the 6th June 2020 – several days after an incident that saw her suffer burns to 40% of the surface area of her body.
Coroner Caroline Sumeray heard that 4 appliances and an Aerial Ladder Platform attended the incident at the second floor flat in Pyle Street, Newport just after 10:00 on the 2nd June after 999 calls were received reporting smoke billowing from the window of the property. Firefighters arrived within minutes, with crews wearing breathing apparatus pulling Ms Osborne from the flames before administering oxygen and drizzling water on her burns.
The inquest heard that Ms Osborne suffered from learning difficulties alongside auditory hallucinations as part of her Borderline Personality Disorder. In the weeks leading up to the incident which caused her death, Ms Osborne had presented at St Mary’s Hospital several times in regards to her mental health. She also had a history of using burning as a self-harm method.
Questions were raised in the hearing after a Serious Incident (SI) report read to the inquest mentioned that a meeting had taken place regarding Ms Osborne’s care – and that a 24-hour care package had been recommended – but no action had been taken to put this in place.
On the day of the incident, after initially being treated at the scene by paramedics and firefighters, Ms Osborne was taken directly to St Mary’s Hospital helipad and then flown to Southampton General Hospital. She was later taken to the Morriston Hospital Regional Burns Unit in Swansea. Despite treatment, Suzette’s body was overwhelmed by her injuries and she passed away several days later following multiple organ failure.
A Fire Investigator’s report into the incident revealed that the most probable cause of the fire was smoking materials – with the most likely ignition point being at the head end of the bed.
HM Coroner, Caroline Sumeray, said it was ‘disappointing’ that action had not been taken to instate the recommendations for a 24-hour care plan and told the court that despite Ms Osborne’s history of poor mental health and previous attempts at overdosing, she could not be sure that the starting of the fire had been deliberate.
Suzette Osborne’s death was recorded as Death by Misadventure, with multiple organ failure alongside burns and smoke inhalation injuries listed as her cause of death.
Discussing the fault lies with the hospital career that shud have put the plan into action this shud not happen, a lady has lost her life becos they didn’t do there job properly, y was the care plan not done, no doubt they will get away with it with all the excuses under the sun, absolutely there fault
Another shambles that needs addressing. … the mental health service. Confusing to say the least.
so sad . Another one failed by the care system