Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0102, written 22 Feb 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Feb 2016 |
|---|---|
| Reference | 2016-0102 |
| Deceased | Patricia Medland |
| Coroner | Lydia Brown |
| Coroner area | Exeter and Greater Devon |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO; 4. as - Bampton Surgery Barnhay Bampton Devon EX16 9NB 4 | CORONER tam Lydia Brown Assistant Coroner for the coroner area of Exeter and Greater Devon. 2 | CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 | INVESTIGATION and INQUEST On 22 June 2015 1 commenced an investigation into the déath 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. 4 | CIRCUMSTANCES OF THE DEATH The deceased died due to exposure to heat and fire smoke, from a fire commenced by herself using petro! as an accelerant. There was no evidence of third part 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 cleceased, 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. CORONER'S CONCERNS a During the course of the inquest the evidence revealed matters giving rise to concern, In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — The care plan in place for the deceased correctly recognised the daughter as having an important role in her mothér’s life, and the evidence was that gerierally 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 fo consider if there was any evidence of relapse in her mother's mental heaith. It was accepted at inquest that the praotice 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. 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. _| YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 5" April 2016. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the tirnetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Goroner and to the following Interested Persons. BE (anche) Northern Eastern and Western Devon Clinical Commissioning Group (who may find it useful or of interest) | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Signed: .Navcrydtrerss Ca senanouseensase Lydia C. Brown” HM Assistart Gorouer Ware and Greater Devon 7 Dated \..sscreee v an perpreeere nevveeers Ceretett invert is}
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Partners: Associates: BAMPTON SURGERY RECEIVED 3 1 M A O ® Barn hay Bampton Devon EX16 9NB 29 March 2016 Lydia C Brown H M Assistant Coroner Exeter and Greater Devon Coroner’s Office Room 226 Devon County Hall Topsham Road Exeter EX2 4QD 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. Yours sincerely Encs: Bampton Surgery Care Plan covering letter template Bampton Surgery Mental Health Review and Care Plan template Bampton Surgery Generic Personalised Care Plan template Copy to: NHS Northern Eastern and Western Devon Clinical Commissioning Group Newcourt House Old Rydon Lane Exeter Devon EX2 7JU Reference: Disclosures to Protect the Patient paragraph 51 GMC: Confidentiality (2009)
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