Recipient

Devon Local Medical Committee

First report 4 Aug 2017•Latest report 18 Jul 2018

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Health professional body. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 3
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Devon Local Medical Committee linked to the concerns in each report. Select any concern, action or position to view the source wording.

18 Jul2018
Plymouth, Torbay and South Devon
Concerns raised2
1. Unclear mental health care pathways for professionals after discharge
2. Lack of triage of GP appointment requests for likely clinical difficulty
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Graeme Robert Mathieson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Graeme Robert Mathieson died following an intentional overdose of prescribed medication. The inquest concluded suicide and identified gross failures to provide basic medical attention while he was in a dependent position, which caused or contributed to the outcome. Concerns included time constraints affecting recognition of his serious psychiatric condition, confusion about mental-health care pathways, and weaknesses in transfer processes.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon Local Medical Committee; that does not assign responsibility.
PFD Monitor interpretation
Unclear mental health care pathways for professionals after discharge
Wider context from the report
“It became apparent during the course of the inquest that a number of professionals (both GPs and care coordinators) were confused or unclear about the correct pathway for ████████ to follow once he had been wrongly discharged from the local CM HT. I indicated that I felt it may be beneficial for Livewell Southwest to add a ‘Professionals’ tab or page to its website so that doctors and other professionals could refer to it in the event of uncertainty. I suggested that it may be sensible for a doctor representing GPs locally to sit down with an individual from Livewell Southwest to ensure that any areas of ongoing confusion were recognised and appropriately addressed. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon Local Medical Committee; that does not assign responsibility.
PFD Monitor interpretation
Lack of triage of GP appointment requests for likely clinical difficulty
Wider context from the report
“At page 20 of my judgement I found that at the appointment on 10 August 2016 the time constraints under which ████████ was obliged to work meant that he was faced with trying to achieve the impossible. I said that I was sure that the very real constraints of time had had a direct impact on the outcome of the appointment. I said that it would have been better if the likely difficulties in this regard had been recognised at the point that Mr Matheson or his sister had asked to have an appointment. If there had been some sort of triage system in place, as I understand to be the case in other practices, this could have been recognised from the outset. I am aware that while some GP practices operate triage system there are plenty of others that do not. I think it may be beneficial for the facts of this case to be shared with all GPs in the area as a learning exercise. What I want to ensure, as far as possible, is that another GP is not placed in the same situation as ████████ on 10 August 2016 with the nearly inevitable conclusion that a patient’s serious psychiatric condition is not recognised. ”
Open source report
22 Jun2018
Plymouth, Torbay and South Devon
Concerns raised1
1. Failure to prevent persons from accessing multiple prescriptions across different GP surgeries
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

David Lee Gomer TRAVERS · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr Travers was found unresponsive and declared deceased on 27 October 2017 after taking illicit and prescription drugs and alcohol, including heroin. The principal concern was that people could access multiple prescriptions from different GP surgeries, with prescription drugs potentially being used to obtain illicit drugs or entering the illegal drugs market.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon Local Medical Committee; that does not assign responsibility.
PFD Monitor interpretation
Failure to prevent persons from accessing multiple prescriptions across different GP surgeries
Wider context from the report
“Evidence from several witnesses indicated that Mr Travers was able to access multiple prescriptions for drugs by moving around Plymouth and the surrounding area and presenting to different GP surgeries as requiring drugs. Evidence also indicated that Mr Travers would sell or barter prescription drugs to obtain illicit drugs. There are apparently measures in place to raise alerts across GP surgeries and NHS Trusts to exchange information about persons who may be attempting to exploit the issuing of drug prescriptions, however given the above evidence, I am concerned that it is nevertheless still too easy for persons to access multiple prescriptions. This presents a risk to those who are able to obtain and take excessive amounts of prescription drugs and a route by which prescription drugs can enter an illegal drugs market ”
Open source report
4 Aug2017
Exeter and Greater Devon
Concerns raised2
1. Failure to review patients receiving extended-term medication for suitability of continued long-term use
2. Failure to prescribe longer-acting rather than shorter-acting benzodiazepines for long-term use
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Carly Marie GORDON · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Carly Marie GORDON was admitted to hospital after a failed attempt on her own life and was later found hanging at home on 27 May 2016 after being discharged to her mother's care. The inquest concluded that she took her own life while suffering from depressive disorder and benzodiazepine withdrawal; concerns related to the long-term prescribing and review of benzodiazepines.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon Local Medical Committee; that does not assign responsibility.
PFD Monitor interpretation
Failure to review patients receiving extended-term medication for suitability of continued long-term use
Wider context from the report
“(2) All patients who receive this drug for an extended period of time should be reviewed by their medical advisors to reassess their suitability for the long term use of this particular medication. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon Local Medical Committee; that does not assign responsibility.
PFD Monitor interpretation
Failure to prescribe longer-acting rather than shorter-acting benzodiazepines for long-term use
Wider context from the report
“(1) The long term use of shorter acting Benzodiazepine instead of longer acting Benzodiazepine in accordance with the British Association of Psychopharmacology Guidelines should be followed when patients are prescribed this drug to avoid dependence. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised2

Unclear mental health care pathways for professionals after discharge

Lack of triage of GP appointment requests for likely clinical difficulty

Concerns raised1

Failure to prevent persons from accessing multiple prescriptions across different GP surgeries

Concerns raised2

Failure to review patients receiving extended-term medication for suitability of continued long-term use

Failure to prescribe longer-acting rather than shorter-acting benzodiazepines for long-term use