A WOMAN’S access to lighters contributed to her death after she died in a fire in her bedroom at a local hospital, an inquest has found.

Sarah Jane Williams died at Prospect Park Hospital on December 6, 2015, but a full investigation into her death only started at the beginning of last month.

Following a two-and-a-half-week investigation, a jury found a number of factors led to her death, including a new smoking ban, lower observation levels, incomplete or poor risk assessments and the poor fire-safety training of staff.

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The panel found Miss Williams had been discovered with lighters on five occasions in the month before she died, and there were two lighters found in her room following the fire that killed her.

And the response of hospital staff to the fire may have also been a factor leading to her death.

The jury agreed the fire safety training of staff was not optimal as evidence showed employees did not know how to follow important fire instructions on Daisy Ward and therefore did not press a key button that would have identified the location of the fire.

A smoking ban introduced at the hospital in October 2015 may have also played a part in Miss Williams’ death as this placed ‘additional demands’ on the ward staff.

Consequently, the jury indicated there was no evidence senior management at the hospital attempted to change staffing levels following the introduction of the ban.

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And one of the contributing factors leading to Sarah Jane’s passing was the ‘lower levels of checking of patients’ on the Daisy Ward, where 36-year-old Miss Williams was staying.

The panel agreed the level of observation of the patient possibly caused or contributed in a ‘more than trivial or minimal way’ to her death.

They determined that if Ms Williams had been on a greater observation level, the fire setting risk could have been minimised or eliminated.

Following the giving of evidence at the inquest, the jury also found risk assessments for the deceased were not updated after November 19 and there was a ‘lack of clear recording of Sarah Jane’s risk of fire setting’ on documents passed between staff.

A care plan for Sarah Jane was not updated after November 27, 2015, either.

Other contributing factors included the management of Miss Williams’ transfer to a secure psychiatric unit at Thames House, which was due to take place two days before she died.

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Her partial non-compliance with her medication could have been an important factor leading to her death too, the jury found.

Sarah Jane Williams’ medical cause of death was burns and inhalation of fire fumes.

The inquest ran from September 6 to September 24 at Reading Town Hall.

A tribute from Sarah Jane’s family read aloud on day one of the inquest described the 36-year-old as a “happy, bubbly young lady” who “overcame many challenges” with her paranoid schizophrenia.

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A 2018 statement from the family also heard at the inquest laid the blame at the hospital for Sarah Jane’s death.

It read: “Our overriding view is that we believe the treatment of Sarah from August 2015 onwards contributed to a serious decline in her mental health and wellbeing.

“Her lack of treatment and scrutiny caused her suffering which ultimately resulted in her loss of life.

“The preparation at the hospital contributed to her death.”