Patricia Bryan had been a resident at the privately-owned Thistle Hill Hall home on Debdale Lane, when the incident happened on 9th March, the inquest at Nottingham Council House heard.
But her family reacted angrily to the decision and said that Ms Bryan had needed caring for in a secure mental health facility and that more should have been done to address the 58-year-old’s 60-a-day smoking habit.
The jury concluded, on the balance of probability, that the schizophrenia sufferer had set fire to her own clothing with a disposable lighter but added “We believe that she did not intend to die.”
Yesterday, Chad reported how Ms Bryan had walked through the home, where she had been a resident since 2007, setting fire to carpets as molten fabric dropped from her clothing,
Staff were alerted by the screams of another resident, but care workers said Ms Bryan did not make a sound as she was engulfed in the fireball.
Instead she ‘walked purposefully’ towards an outside smoking area, where staff caught up with her and put out the flames with a fire extinguisher, the inquest at Nottingham Council House was told.
After the blaze, in which she received 68 per cent burns, she continued to walk around and then sat down outside and ‘rocked gently and mumbled to herself’, the inquest heard.
She died from her injuries seven hours later after being flown by air ambulance for specialist care at a hospital in Birmingham.
The tragedy triggered a multi-agency investigation involving the Nottinghamshire Healthcare NHS Trust, the Health and Safety Executive (HSE) police, social services, and the home.
Describing the incident yesterday, former healthcare assistant Alex Robertson said: ““Pat was on fire and she was walking towards the rear exit. The carpets were also on fire and I reached Pat just as she got to the bottom of the steps and I discharged the fire extinguisher at her.
“She had stopped walking and was just stood facing me.”
Earlier today, assistant coroner Jane Gillespie directed the 10-strong jury to rule out verdicts of suicide or neglect due to a lack or evidence.
Speaking after the hearing, daughter Tracy Stone, from Mansfield Woodhouse, said: “There should be a law preventing residents in homes like this from carrying lighters or even a full smoking ban.
“My mum was not getting the care she needed and our calls for her to be cared for in a supervised mental health unit had been ignored.
“I loved my mum dearly and I will always miss her.”
Ms Bryan was banned from having her own lighter in the home, the inquest heard.
But she would frequently buy them when she went into the community unsupervised, or borrow a lighter from other residents.
The inquest also heard that a room search had not taken place when staff realised she had been smoking in her room in the hours leading up to her death.