Finding into death of Moufid Sawan

61y · Male·Complications of cutaneous burns

A 61-year-old man with severe chronic schizophrenia and extensive history of arson, suicide attempts and self-harm was admitted as a voluntary patient to a psychiatric inpatient unit and later made involuntary. Despite clinical concerns about his mental state, he was progressively granted unaccompanied leave. A patient/visitor reported he was asking others to buy petrol for him around 2:30pm on 15 November 2011, but this critical information was not effectively communicated to the treating team. During afternoon leave, he purchased petrol, doused himself with it, and self-immolated, sustaining 90% full-thickness burns. He died the following day. The coroner found preventable failures: clinicians lacked access to historical records documenting his arson history and past suicide attempts, communication of the petrol-seeking report broke down, and leave was not reviewed when critical new risk information emerged. Had staff known about the arson history and the petrol request, leave would have been cancelled.