Finding into death of Mrs R

57y · Female·Asphyxia - Inhalation of liquefied petroleum gas (LPG)

Mrs R, a 57-year-old woman with bipolar disorder, borderline personality disorder, and depression, died from asphyxia by inhalation of liquefied petroleum gas. On 31 March 2024, family unable to contact her requested a police welfare check. Police obtained information about her mental health history, previous suicide attempts, recent breakdown, and family separation, but determined welfare check was unnecessary as there was no 'imminent and serious harm'. The coroner found the welfare check should have been conducted given her significant risk factors, though likely would not have prevented her death as she had probably already deceased. Key lesson: comprehensive risk assessment in welfare checks requires consideration of accumulated risk factors, not solely recent direct threats. Clear police protocols for welfare check decision-making are essential.