Investigation and inquest
On 24 December 2012 I commenced an investigation into the death of Kathleen Rosemary Dixon, 64 years. The investigation concluded at the end of the inquest on 1 November 2013. The conclusion of the inquest was that Kathleen Rosemary Dixon died as a consequence of her own actions whilst suffering from an acute episode of mental illness. The medical cause of death was Drowning.
Circumstances of the death
Mrs Dixon was receiving treatment for mental illness which was escalating and its severity was not recognised by those treating her. She drowned in a river.
Coroner’s concerns
(1) This is a repetition of similar circumstances in a number of previous Inquests and I think the Trust needs to be assessed independently.