A vulnerable woman died of hypothermia in a freezing council home which she was unable to heat.
Cass Terry had struggled with mental health issues and was wary of asking for help from support services, an inquest at Exeter Coroner Court heard.
As well as being freezing cold, her home was not properly equipped and she had no fridge or microwave.
The 55-year-old, a musician and artist, had been under the care of Devon's Community Mental Health Team until November 2020.
However, she was found dead a year later when the fire brigade broke into her property after a neighbour reported seeing her lying on the floor when he peered through the letterbox.
Devon Live reported Cass had suffered with self-neglect due to being diagnosed with a persistent delusional disorder.
Her sister, Anne-Marie Rogers, questioned in a statement whether more could have been done to support Cass and whether a lack of care contributed to her living in poor conditions.
She said: "I have concerns about her death and the care she received or did not receive leading up to her death, which I feel possibly contributed to her death."
She told how her sister, an alcoholic, drank heavily to self-medicate. A post-mortem examination confirmed the cause of her death was hypothermia and that she had not been intoxicated at the time of her death.
Regarding her lack of heating, Anne-Marie added: "I have never known her to use heating, despite living in the flat for several years."
Describing her past struggles, she continued: "She was put into care at age of 14 by Devon County Council and was also repeatedly sectioned in recent years. She had been homeless, once living in a cave.
"She was suspicious of services given how she had been detained in the past."
Devon Partnership Trust mental health nurse Jennifer Kent told the inquest how she came under the care of the community team in July 2019 following a hospital admission.
She recalled: "She was struggling in her flat and was feeling quite isolated. She was keen to engage in therapy."
Cass, who was born in Hertfordshire, was appointed a support worker who would go to her home once a fortnight and was said to have tried to help her buy a second-hand fridge/ freezer but she declined stating that she was awaiting a new kitchen to be fitted.
No concerns were noted about the lack of heating and the inquest heard she was offered a social care package but declined because she felt she was being well supported by her neighbour.
In October 2020, Cass discharged herself from the service, reporting that she was feeling “very stable”.
Recording a conclusion of natural causes, area coroner Alison Longhorn said to her family: "It must have been very difficult to lose Cass in these circumstances and very difficult for you to accept she was very against getting help from anywhere and the help she needed she did not get."
Anne-Marie added: "Despite being well known to Exeter mental health services, having been sectioned six times in four years including several occasions in Exeter, she was discharged during a lockdown and judged a low risk.
“Yet the mental health services knew she couldn’t cook for herself, didn’t have a fridge, wasn’t taking her medication, and had been sectioned the year before.
"She was discharged to her GP who didn’t see her once, and wasn’t aware she had a drink problem.
“Cass didn’t know how to use her heating. She died cold and undernourished on the floor of her council flat, alone, apart from her pet dog Stanley.
"Cass’s death is an indictment of current mental health provision.”
