Hannah Kilgallon inquest: Discharge criticised by coroner

Hannah Kilgallon had been on leave from Lynfield Mount Hospital in Bradford when the fire took place at her home

A woman met a "horrifying" death in a house fire days after she was discharged from a mental health unit, a coroner has ruled.

Hannah Kilgallon, 50, who had bi-polar disorder, was discharged from Lynfield Mount, Bradford, in February 2019.

An inquest heard white spirit, which she drank during a psychotic episode, ignited and started the fatal fire.

A coroner said the discharge was agreed to with "insufficient regard" for her recent mental health struggle.

Recording a narrative conclusion, Assistant coroner Oliver Longstaff said the death was "horrifying" and probable that the fire was started by accident.

Bradford Coroner's Court was previously told Ms Kilgallon had been admitted to Lynfield Mount as a voluntary patient after police found her naked on a bus.

The inquest heard she had been "erratic" in her behaviour and suffered from mental health issues for some time.

Following her discharge, she failed to return when agreed and was "absent without leave", before her death at her Haworth Road home a day later.

Mr Longstaff said a police welfare check was requested on the day she died, but it was unlikely to have been carried out as she was a voluntary patient.

The hearing was told she made a number of 999 calls just before her death, claiming her boyfriend had been missing for "10 million years" and that she had set herself on fire.

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A police call handler who spoke to Ms Kilgallon said laughing could be heard on the line and she did not hear her claim to have drunk turpentine.

Post-mortem examinations found Ms Kilgallon had drunk white spirit and died from burns sustained in the fire at her home.

Her family had previously said they believed her death was preventable.

In the months after her death, Bradford District NHS Care Trust said it had reviewed and changed practices around leave and monitoring of patients.

Kelly Barker, from the trust, said it had undergone a "rapid improvement week" to look at service changes to keep patients safe.

Mr Longstaff said the decision to discharge Mrs Kilgallon initially from Linfield Mount was not taken with enough regard for her recent episodes, but he was content with the training outlined after her death.

He praised the "dignity and courage" of Mrs Kilgallon's two daughters throughout the inquest.

"Their mother's mental illness was a significant impact on their childhood," he said.

"There can be no doubt that they cared for her and about her with love and devotion, and that was reciprocated."