Source · Prevention of Future Deaths

Patricia Medland

Ref: 2016-0102 Date: 22 Feb 2016 Coroner: Lydia Brown Area: Exeter and Greater Devon Responses identified: 1 / 1 View PDF

The patient's daughter was unaware of her designated role as a protective factor in the care plan, potentially preventing her from recognising signs of her mother's mental health relapse.

Date 22 Feb 2016

56-day deadline 18 Apr 2016 est.

Responses identified 1 of 1

Community health care and emergency services related deaths

Coroner's concerns

AI summary

The patient's daughter was unaware of her designated role as a protective factor in the care plan, potentially preventing her from recognising signs of her mother's mental health relapse.

View full coroner's concerns

During lhe course of the inquest the evidence revealed matters giving rise to concern; In my opinion there is & risk that future deaths will occur unless action is taken In the circumstances it is my statutory duty t0 report to you: a9 follows: and

The Care plan in place for the deceased correctly recognised the daughter as having an important role in her mother'$ life and the evidence was that generally information was shared between the family_ On this occasion, the daughter was not aware of the care plan; or that she was considered to be a protective factor: Had she know; she may have been In a better posilion to consider if there was any eviderice of relapse in her mothers mentai health; It was accepted at inquest that the practice had not discussed this a8 a matter for further discussion and debate, although the unexpected death 0f this patient had been considered by the practice in their regular meetings:

Responses

1 respondent

Brampton Surgery Other

29 Mar 2016 PDF

Action Planned

The practice agreed to encourage sharing appropriate information with relatives and carers, always discussing this with the patient, and has informed the NHS Northern, Eastern and Western Clinical Commissioning Group of the issues raised for wider sharing. (AI summary)

View full response

Dear Ms Brown Mrs Patricia Medland (deceased) Inquest held on 12 January 2016 Thank you for your letter of 7 March 2016 and enclosed Regulation 28 Report requesting a substantive response. Mrs Medland’s death, the points raised within your report, and your recommendation have been discussed further in our Practice. We agreed that the sharing of appropriate information with nearest relatives and carers should be encouraged and we will always discuss this with the patient. In most cases this will require their explicit consent and we would only share information without consent if we believed the patient or others would be at immediate serious risk if we did not Cref I enclose a copy of our Care Plan covering letter which encourages the patient to share information, together with the Care Plan templates that we use. I have also informed , Governance Systems and Process Project Officer, NHS Northern, Eastern and Western Clinical Commissioning Group of the issues raised. He has informed me that this will be shared more widely and I will co-operate with the CCG further as required. Continned overleaf ...

I hope that you are satisfied with this response. I have been in contact with (daughter) and agreed with her I would contact her further to confirm I had complied with your Regulation 28 Report recommendations. I look forward to hearing from you.

Report sections

Investigation and inquest

On 22 June 2015 commenced an investigation inlo the death of Patricia Mary Medland: The investigation concluded at the end of the Inquest on 12 January 2016. The conclusion of the inquest was open conclusion

Circumstances of the death

The deceased died due to exposure to heat and fire smoke, from a fire commenced by herself using petrol as an accelerant There was no evidence of third part involvement: At the time of her death; the deceased was suffering from & severe mental illness and it is likely that this impacted on her actions A care plan had been prepared, reviewed and agreed with the general practitioner and the deceased: It made reference to the daughter being a protective factor in the safety of the deceased, but the daughter did noi know of the existence of the care plan of her mother's curent diagnosis_ or that she was named within the document:

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2016-0102
Date of report: 22 February 2016
Coroner: Lydia Brown
Coroner area: Exeter and Greater Devon

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 18 Apr 2016 (estimated).

Sent to

Bampton Surgery

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.