There were "missed opportunities" before a grandfather accidentally set himself on fire at his home in Kirkby, an inquest has heard. Thomas Norton, known to family and friends as Tommy, died on December 13, 2024, a day after he spilled lighter fluid on his dressing gown and ignited it while testing the lighter.
At an inquest at Bootle Town Hall on October 20, senior coroner Anita Bhardwaj heard how the 62-year-old, who had a long history of medical issues including heart failure and COPD, had spent a year in and out of hospital. He presented at Aintree University Hospital on November 21, 2024, and spent two weeks there before being discharged on December 5.
Hospital readmission and discharge
Just two days later, Mr Norton was readmitted to hospital with breathlessness, a cough and palpitations. He chose to go to the Royal Liverpool Hospital on December 7, telling staff he was not satisfied with his recent care at Aintree Hospital.
A statement from Dr Adamola Momoh, a doctor at the Royal, detailed how Mr Norton had smoked since he was 16, smoked cannabis at night, and averaged 15 cigarettes a day. The father, who lived in a bungalow in Kirkby with his long-term partner Linda Stewart, also had anxiety and depression. During his time at the Royal, Mr Norton told professionals he suffered from nightmares and struggled to sleep, and he barricaded himself in his hospital room.
Mental health nurse Caroline Jennings visited Mr Norton and referred him to the delirium and dementia team. However, he was discharged on December 11 before the team could see him.
Home visit on his birthday
Shortly after he returned home, Mr Norton's partner Ms Stewart contacted Wingate Medical Centre, concerned about his confusion and sleeplessness. Dr Stephanie Lamb conducted a home visit at around 4pm on December 12, Mr Norton's 62nd birthday. Dr Lamb said she believed his suspected delirium was due to a chest infection.
She told the court: "I discussed with both of them the next course of action. Tommy was quite complex so I liked to lay out each individual thing, having spoken to Ms Stewart, the main concern was the confusion."
"We spoke about the potential reasons he may be confused. I thought it might be an undiagnosed delirium linked to his recent chest infection. This can last longer than the infection, sometimes hours and days."
Following the visit, Mr Norton went to refill a Zippo lighter with lighter fluid, accidentally spilling it onto his dressing gown. When he tested the lighter, he set his clothing alight. Ms Stewart used water to extinguish the fire before Merseyside Fire and Rescue Service arrived to find Mr Norton in his kitchen with serious burns to his neck, head, torso, groin and legs. He was taken to hospital but died the following day.
Family concerns and complaint
After his death, Mr Norton's family submitted a complaint to Liverpool University Foundation Trust (LUFT) over his care and repeated discharge, despite concerns about his mental welfare. His daughter, Gemma Stewart, raised concerns about her father having repeatedly absconded from hospital earlier in the year, and about Dr Lamb's decision to refer him to the dementia and delirium team on the morning of December 13 without knowing what had happened the night before.
Gemma described collecting her father from the Royal after his discharge, where he was sat in a wheelchair "screaming at people" claiming people had been trying to kill him in the hospital. She said: "People have had to die for steps to be taken." She also noted her father had previously been under the Deprivation of Liberty Safeguard (DoLS), a legal framework for those lacking mental capacity to consent to care or treatment.
Tearfully, Gemma added: "It shouldn't take for someone to set themselves on fire for something to change, we shouldn't be sat here. I have to look after my mother because of what she saw. She had to put out a fire that engulfed my dad, she has PTSD because of it and now she rings me telling me she smells smoke in the middle of the night."
Dr Lamb explained her referral was to give the family "support in the community" without immediate concern. Karen Holden, director of nursing for safeguarding at LUFT at the time, said a review took place following a referral from Merseyside Fire and Rescue Service and the family's complaint. She said the discharge was deemed an "easy discharge" because Mr Norton was returning to a home where his partner lived, but lessons have been learnt. A new policy has been introduced and implemented that takes family concerns and arrangements into consideration.
Asked by Ms Bhardwaj whether Mr Norton should have been allowed to be picked up from hospital in his condition, Ms Holden said: "Absolutely not." She did not dispute Gemma's recollection of events. The family said they raised "multiple" safeguarding concerns with staff at both hospitals; Ms Holden said where these were logged depended on how staff interpreted the concern.
Conclusion and family tribute
Senior coroner Ms Bhardwaj concluded Mr Norton's death was an accident, but noted a series of missed opportunities before his death for a multi-disciplinary approach to his discharge, including in discharge planning, safeguarding and communication with his family. She said: "Thomas remained a smoker despite repeated advice and his significant underlying health conditions and meant the risk of cigarettes and lighter fluid persisted." She noted changes have been implemented since his death, and told his family he sounded like an "absolutely amazing person".
In a tribute, Mr Norton's family said: "Our dad was kind, caring and gentle. He was always there for advice and would listen to anyone's problems. He wanted the best for everyone. He loved watching Liverpool play and celebrated their wins with a glass of whisky."
"He was the best dad and grandad and would have done absolutely anything for his grandchildren who all miss him more than anything in the world. He lived for his lifelong partner Lin who is struggling to navigate life without him."
"People are asked to describe someone as a person but that's so difficult he was just our Dad and we took that for granted. I just hope that he left us knowing how much we loved him. Dad was also a grandad to nine grandkids that he adored and loved so much and also a great father-in-law to his in-laws."
