Patricia Mary Medland · Prevention of Future Deaths report

On 22 June 2015 I commenced an investigation into 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.

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 party involvement. At the time of her death, the deceased was suffering from a 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 not know of the existence of the care plan, of her mother's current diagnosis, or that she was named within the document.

The care plan in place for the deceased correctly recognised the daughter as having an important role in her mother's 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 position to consider if there was any evidence of relapse in her mother's mental health.

It was accepted at inquest that the practice had not discussed this as a matter for further discussion and debate, although the unexpected death of this patient had been considered by the practice in their regular meetings.