A family of a woman who died in a house fire was shocked to learn her carers were not aware of a document designed to prevent such a tragedy.
Yasmin Siddiqi, 41, died in a blaze in her basement flat on Rodney Road in Great Yarmouth on October 26, 2018.
At the time she was under the care of the Norfolk and Suffolk NHS Foundation Trust (NSFT) and adult social services.
An inquest into her death, at Norfolk Coroners Court, heard on Monday (February 3) that while there was no evidence of systematic failure, Miss Siddiqi's carers were not aware of a safeguarding policy document intended to prevent risks associated with self-neglect and hoarding.
Assistant Coroner for Norfolk Simon Milburn said a fire safety inspection of Miss Siddiqi's flat, deeming the premises high risk, should have triggered safeguarding measures including a mental capacity assessment.
And, making a statement after the inquest, Sharon Allison, solicitor for Miss Siddiqi's family, said: "It was genuinely shocking and devastating to the family to hear in evidence that so many health professionals responsible for Yasmin's care were unaware of the existence of the document at all."
Miss Siddiqi, who had suffered with mental health difficulties since her teens, was a compulsive shopper and hoarded the items in her flat.
She had been admitted to Northgate Hospital in Great Yarmouth three times in 2018 and at one point spent six months there.
After an assessment in February 2018 a care plan was put in place where she would have 12 hours support every week.
It appeared, however, that her hoarding worsened - and a fire safety inspection of the flat only weeks before her death suggested a number of changes including reducing the clutter by 50pc but the recommendation was not carried out.
The inquest also heard NSFT staff had recommended Miss Siddiqi, who was a heavy smoker, needed to be rehoused due to self-neglect and hoarding.
Mr Milburn concluded that her death was accidental, most likely caused by a carelessly discarded cigarette.
Miss Siddiqi was originally from Birmingham and moved to Great Yarmouth in 1997.
During the inquest, her brother Zahid Verrier said she had been a fun-loving and outgoing woman until a sexual assault when she was 15-years-old destroyed her life.
'A growing problem'
In a statement on behalf of the deceased woman's family, Ms Allison said: "Evidence from the fire service confirmed that hoarding is a growing problem in Norfolk and represents a significant challenge to them.
"The family want to offer their heartfelt thanks to all of the emergency services on the day, who made truly heroic decisions in Yasmin's rescue from her flat.
"Yasmin's family hope that the evidence, recommendations and her untimely and tragic death will bring about the necessary changes within all health organisations to prevent further loss.
"The family will need to take some time now to consider the evidence they have heard and consider the options available to them."
'Sad and tragic loss'
Diane Hull, Chief Nurse at the NSFT, said: "We're really sorry about Miss Siddiqi's sad death. Our thoughts are with her family, friends and those who have worked with her for many years.
"This really is a very sad and tragic loss of life for such a young woman.
"I would like to meet with Miss Siddiqi's family, and will meet with them if they wish."
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