A grandmother who died after setting herself on fire could have been making a cry for help rather than trying to take her own life, a coroner has concluded.

But her daughter feels that after numerous suicide attempts and deteriorating mental and physical health her mum had “had enough” and wanted to die.

Jessie Mary Hutson’s body was found sitting in her armchair at her supported accommodation in Gravesend after a small blaze in the flat.

The 68-year-old died of asphyxia due to suffocation and the fire had burnt deep into her skin, an inquest at Maidstone’s Archbishop’s Palace was told last week.

Although it was accepted Mrs Hutson started the fire at Watling Court, Ifield Way, deliberately on Sunday, January 31, last year, coroner Roger Hatch said he could not be certain her death was a suicide.

Returning a narrative conclusion, Mr Hatch said: “Jessie Mary Hutson died as a result of her setting herself on fire as a cry for help while suffering from mental health issues.”

But daughter Joanne Stevens, who works as a carer and often looked after her mum, said this time was different to the pensioner’s previous suicide attempts.

The 45-year-old mother of two, who also lives in Gravesend, said: “Before when she tried to kill herself she always left a note or a message on my answer machine, just something simple like ‘I love you, I’m sorry’. The fact she didn’t this time says to me that she did actually mean it.

“Her physical health had deteriorated as well as her mental health and I think she’d just had enough.

“If it was a cry for help that makes me sad because she could have still been here.

“I wouldn’t have minded if he’d given a suicide conclusion as I don’t believe there’s a stigma attached to suicide or mental health issues.”

Mrs Hutson, who had been receiving treatment from mental health workers since the 1980s, had borderline personality disorder, battled a number of issues including anxiety and had previously had an alcohol problem.

Mrs Stevens recalled: “Over the last few years the spaces between the good times and when she was really ill got less and less. Towards the end she was constantly depressed and anxious.

“I’ve been dealing with her on my own since I was 15. All I ever wanted was a mum, someone I could ring up and go for lunch with or who could babysit my kids for me. But we never really had that kind of relationship, it was like having another child sometimes.”

But at Mrs Hutson’s funeral her daughter began remembering the good times they shared when she was younger.

She said: “Mum had OCD (obsessive compulsive disorder) and when we were kids that came out in quite strange ways.

“Our toothpaste used to be on our toothbrushes when we got in from school and our baths would have been run. The moment you put a cup down it was whipped away.

“She was there with me when I went into labour with my eldest son at home and she stayed with me all night.

“There were good times. I hate using the word ‘normal’ but she could be a lovely, normal person.”

She has only a few photos of her mum, taken many years ago, as Mrs Hutson disliked having her picture taken.

Mrs Hutson, who was born in Southend but grew up in Northfleet, leaves two daughters, two grandchildren and two step-grandchildren.

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Coroner Roger Hatch criticised the Kent and Medway NHS and Social Care Partnership Trust’s crisis resolution home treatment team (CRHTT) for its treatment of Mrs Hutson the weekend she died. He said: “She should have been provided with respite or residential care over the weekend.”

The coroner said if Mrs Hutson had been taken somewhere experienced in dealing with severe mental health issues she may still be alive. She had set her clothing alight earlier the day she died and a carer had put the flames out and taken cigarette lighters off her.

The trust claimed its CRHTT team had not been told about this, or that she was threatening suicide the day she died, but both Westminster Home Care and the ambulance service disputed this.

The trust said if it had known about Mrs Hutson’s behaviour that day it would have sent a staff member to see her sooner.

Mrs Hutson had spoken to the mental health team the day before she died and a member of staff arrived with anti-anxiety medication shortly after her death. A meeting to discuss her future care had been arranged for the day after she died.

Community nurse Safraz Joomun told the hearing Mrs Hutson admitted to having thoughts about suicide but said she was not planning to actually take her own life and he believed she was safe where she was.

The grandmother had also called the emergency services dozens of times saying she needed to go to hospital, she had lost her medication, she was lonely and she needed help.

She phoned the fire service minutes before the fatal blaze.

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Jessie Mary Hutson’s death had already been investigated by an independent panel, which made recommendations that it hopes will save lives.

The review was commissioned by the Kent and Medway Safeguarding Adults Board.

The report criticised various agencies involved in Mrs Hutson’s care for not fully working together and said Kent and Medway NHS and Social Care Partnership Trust (KMPT) should have taken the lead in making sure this happened.

It said if someone from KMPT’s crisis team (CRHTT) had attended the day Mrs Hutson died “her anxiety may have been reduced, especially once she received her missing medication, and her self-harming behaviours may not have escalated, or CRHTT may have recommended that she be taken to hospital for further assessment. This would have limited her access to items that she could have used to self-harm, which may have ensured her safety on that day”.

The board is made up of council representatives, healthcare providers, the fire service, police and further education providers, among others.

The report recommended all agencies work together more effectively and ensure staff are properly trained to recognise signs of mental health issues and act accordingly.

Deborah Stuart-Angus, independent chairman of the board, said: “We would like to express our deep sorrow and regret that a person should die in such horrific circumstances and on behalf of the board, and all of our partners across Kent and Medway, I give our sincere and heartfelt condolences to her family.

“The commissioning of this Safeguarding Adults Review has created the opportunity to examine the complex circumstances of this case in detail. It marks our determination to learn any lessons for the future to help prevent a similar incident from occurring.

“The board fully accepts both the findings and recommendations of the review.”
In light of the report the coroner felt he did not need to make any further recommendations.

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