Fire death man's 'risky behaviour' ignored by health and social services
A vulnerable man who had a history of hoarding and lighting fires died after being failed by health and social services, an inquest has heard.
Bob Crane, 61, who had bipolar disorder, suffered fatal smoke inhalation at his Bristol flat.
Avon and Wiltshire Mental Health Partnership said it was cooperating with the inquest.
After Mr Crane's death in 2014, Bristol Safeguarding Adults Board (BSAB) launched a serious case review.
In a report presented at Flax Bourton Coroners' Court, the BSAB said he died because his mental health history was "overlooked" and his risky anti-social behaviour was not seen as a symptom of his psychiatric condition.
The inquest heard Mr Crane had cooked on barbecues with liquid gas, because his gas and electricity supplies had been cut off.
In the six months before his death, firefighters were called to his flat in Carolina House in Dove Street, Kingsdown, four times after neighbours reported he was lighting fires, the inquest heard.
It was also told Mr Crane had been treated in hospital for a bipolar disorder, in 2012.
The safeguarding report found Avon and Wiltshire Mental Health partnership (AWP) failed to see his "risky and chaotic lifestyle" was a symptom of his underlying mental disorder.
AWP felt his anti-social behaviour was "down to choice - rather than a symptom of his condition", the report stated.
Agencies lost sight of the fact that he had been detained under the Mental Health Act and was entitled to ongoing support, it said.
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, offered condolences to relatives and friends of Mr Crane.
"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.