A man died after starting a fire in his living room, an inquest heard. Mark Bramall died on June 3 in his flat this year after setting fire to a chair, Bolton Coroners' Court heard.
Recording an open verdict, coroner Prof John Pollard said he was unable to determine if he meant to take his own life or died accidentally. The inquest heard from his parents and a number of mental health professionals who described the difficulties he had with drug addiction and his mental health. He had been suffering with paranoid schizophrenia for at least 30 years, the court heard.
His parents, Gerald and Stella Bramall, told the court that they did their best to help their 51-year-old son but he would often relapse as he "couldn't help himself". They said he would instantly spend any money he received through benefits on drugs, with drug dealers exploiting this. They would help him buy food and other essentials as he would never have any money.
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The court heard that Mark had been sectioned on a few occasions but mental health teams struggled to help him unless he would stop using drugs "but that was the problem," his father Gerald said. Paying tribute to his son, he said: "We all miss Mark so much and am devastated he is not here anymore". His mother Stella also paid tribute saying: "I love him so much no matter what he did I love him more than anything."
Community psychiatric and mental health nurses told the hearing Mark had a lot of contact with them and showed insight into his mental health issues. He would often describe feeling paranoid about drug dealers searching for him and hearing voices. However, he would often ignore phone calls or visits from these teams too.
Mark was often referred to the Achieve service in Bolton for drug and alcohol recovery but he did not fully engage with this, the inquest heard. He had also presented on a number of occasions to A&E in Bolton and had been kept in hospital as he would often be under the influence of drugs.
A fire scene investigator with Greater Manchester Fire and Rescue Service, Peter Stone, described the incident which led to Mark's death on the evening of June 3. He said firefighters had to break into Mark's flat on Foxendale Walk, Bolton, which was made difficult as he had barricaded the door with chairs and a mattress.
The flat was "filled with smoke," he said, with Mark found unresponsive in his kitchen. He was immediately treated by paramedics but was pronounced dead at the scene.
The door to the living room had also been partially barricaded.
Investigations found the fire had started after an armchair in the room was set alight by an open flame. Mr Stone said the most likely scenario was that Mark had set fire to the armchair while in the lounge but then the smoke became "unbearable" and he left before collapsing in the kitchen. Neighbours who saw smoke coming from the windows then called 999. Police Coroners' Officer, Andy Pickles, agreed with this, telling the court police believed the fire was started by Mark but he may not have intended to end his life.
Marc Lowden, an incident report author for Greater Manchester Mental Health Trust, said learnings had been made since Mark's death. He said there was a potential his risk should have been escalated. He also cited issues around note taking in reference to his care, which has since improved, he said. He pointed out that nationwide there are not enough experienced staff to deal with complex cases like Mark's.
Mark's cause of death was given as smoke inhalation.
Recording an open verdict, Prof Pollard placed a lot of blame for Mark's addictions and poor mental health on drug dealers who he was "frightened of" and which led to him barricading his doors. He could not conclude that Mark intended to kill himself as he tried to leave as his home when it filled with smoke. But the smoke was "too strong" and he was "overcome by it", he said.
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