Concerns raised 2 Failure of the Special Allocation Scheme to meet the needs of autistic patients View source Lack of appropriate care and support for autistic people in crisis without a treatable mental health condition View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Benjamin Robert Compton · 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
Benjamin Robert Compton, who had autism, experienced a deterioration in his physical and mental wellbeing and escalating distress. In the early hours of 1 February 2022, he left his supported accommodation and was hit by a lorry on the M5. The substantive concerns included gaps in support for autistic people in crisis and the inability of the Special Allocation Scheme to meet Benjamin’s needs.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Special Allocation Scheme to meet the needs of autistic patients
Wider context from the report “(2) Benjamin was removed from his GP practice due to violent behaviour and allocated to the Special Allocation Scheme. This scheme was not able to meet the needs of a patient such as Benjamin with a diagnosis of Autism Spectrum disorder .
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate care and support for autistic people in crisis without a treatable mental health condition
Wider context from the report “(1) The evidence reveals that there was a gap in the provision of care for individuals suffering with autism and in crisis, that remains the case today both in Devon and nationally . Evidence was heard that a gap exists with autistic people in distress and or dysregulation with no treatable mental health condition and there is a grey area around treatment. This is beyond the skills of social care providers . And unless the individual meets the criteria for treatment under the Mental Health Act there is very little support .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Devon Adult Autism Intervention Team as a countywide service for autistic adults.
Verbatim wording from the response “At the time, as described by ████████ in her testimony in court, the Devon Adult Autism Intervention Team (DAAIT), had recently been commissioned to provide a countywide service for autistic adults with the aim to:” Source location Response from Devon Partnership Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Primary care and GP-related questions fall outside the Trust’s remit, so it cannot comment on them.
Verbatim wording from the response “Benjamin was removed from his GP practice due to violent behaviour and allocated to the Special Allocation Scheme. This scheme was not able to meet the needs of a patient such as Benjamin with a diagnosis of autism spectrum disorder.” Source location Response from Devon Partnership Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Learning Disability/Autism Outreach service is not commissioned to provide crisis support or intervention like mental health crisis teams.
Verbatim wording from the response “As part of the regional development a Learning Disability/Autism Outreach team has been commissioned to sit alongside each unit as part of what is being seen as regional a Learning Disability/Autism service. The LD/A outreach linked with The Brook, is due to become operational at a similar time to the unit opening.” Source location Response from Devon Partnership Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation DAAIT is not commissioned to provide urgent, emergency or crisis responses for autistic people in distress.
Verbatim wording from the response “However, had DAAIT been operational at the time of Mr Compton’s distress there still would not have been a specific dedicated autism crisis pathway that he could access. The DAAIT service operates with a duty worker system 5 days per week, staffed by team members. Because of the low demand on duty in terms of volume of queries, and DAAIT service not commissioned to provide an “urgent response”, there is a time frame for response of 48hrs, predominantly this accessed via email queries. This provision is noted in the service Standard Operating Procedure. If there was a significant concern that there was an immediate threat to life then the staff member dealing with the query would contact the police via 999.” Source location Response from Devon Partnership Trust
Open published response
31 Jan 2025 Alexander Channing · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Lack of responsible clinician involvement in discharge planning View source Absence of a policy encouraging repeated proactive approaches to obtaining patient consent for information sharing View source Lack of training for wellbeing services regarding students diagnosed with Emotionally Unstable Personality Disorder View source Failure among CMHT staff to recognise direct transfer of patient care between CMHT trusts without prior GP registration View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Alexander Channing · 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
Alexander Channing, known as Alec, was found suspended by a ligature in his university halls of residence on 27 January 2022 and was pronounced dead at the scene. The report records concerns about delays in transferring his mental health care, discharge planning without Home Treatment Team involvement, postponed assessment, limited proactive attempts to obtain consent to share information, and a lack of relevant training and policies.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of responsible clinician involvement in discharge planning
Wider context from the report “iii. There was a lack of involvement of a responsible clinician in the process of discharge planning from the district hospital in Exeter to the care of Bournemouth CMHT at Dorset Healthcare NHS Foundation Trust.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a policy encouraging repeated proactive approaches to obtaining patient consent for information sharing
Wider context from the report “iv. There is no policy in place at Devon Partnership NHS Trust which encourages a repeated proactive approach in seeking consent from a patient to share information at relevant times.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training for wellbeing services regarding students diagnosed with Emotionally Unstable Personality Disorder
Wider context from the report “i. There is no training provided to the wellbeing services at the Arts University Bournemouth in relation to students diagnosed with Emotionally Unstable Personality Disorder.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure among CMHT staff to recognise direct transfer of patient care between CMHT trusts without prior GP registration
Wider context from the report “ii. There appears to be a failure amongst staff at the Exeter CMHT to appreciate that there can be a direct transfer of a patient’s care to another CMHT trust without the need for a patient to have to first register with a GP surgery
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain an agreed standard operating procedure for transferring patients between community mental health services, including patients without a registered GP.
Verbatim wording from the response “Patient transfers to out of area services remain a challenge for all NHS providers. We have an agreed standard operating procedure that articulates the process to collaboratively transition a person between community mental health services from Devon Partnership Trust to another Trust. At times the referring team may still experience local challenges in relation to an out of area transfer, as the policy relates to DPT’s processes only. Details on referring a person to another Trust where they do not yet have a GP can be found on page 6 point 6.6, this is the specific detail,” Source location Response from Devon Partnership NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add discharge-planning requirements to the Liaison Psychiatry standard operating procedure for consultant consideration of 48-hour follow-up and documentation of the rationale when follow-up is not required.
Verbatim wording from the response “In terms of discharge planning from Liaison Psychiatry, in relation to the planned discharge from the district hospital in Exeter, I can confirm that the following paragraph has been added to the Liaison Psychiatry Services Exeter, Torquay and Barnstaple Specialist Services Directorate Standard Operating Procedure. It gives detail on page 12 of the attached document.” Source location Response from Devon Partnership NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing standard operating procedure addresses transfers without a registered GP and provides for continuity and managed handover.
Verbatim wording from the response “Patient transfers to out of area services remain a challenge for all NHS providers. We have an agreed standard operating procedure that articulates the process to collaboratively transition a person between community mental health services from Devon Partnership Trust to another Trust. At times the referring team may still experience local challenges in relation to an out of area transfer, as the policy relates to DPT’s processes only. Details on referring a person to another Trust where they do not yet have a GP can be found on page 6 point 6.6, this is the specific detail,” Source location Response from Devon Partnership NHS Trust
Open published response
Concerns raised 4 Failure to achieve clear communication of key information within community mental health teams View source Failure to routinely detect Clozapine-associated cardiomyopathies View source Limited provision of Clozapine side-effect and red-flag information to patients attending GP practices View source Failure to achieve clear communication of key information with other agencies involved in patient care View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
William Antony Northcott · 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
William Antony Northcott, who had treatment-resistant schizophrenia, was found deceased on 13 July 2021 after suffering a sudden fatal cardiac arrhythmia. The report raised concerns about the adequacy and consistency of information on clozapine side effects and cardiac warning signs, the detection of cardiomyopathies in patients taking clozapine, and communication between agencies and care teams.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to achieve clear communication of key information within community mental health teams
Wider context from the report “It is clear that patients suffering with treatment resistant schizophrenia are complex, and as such there are often a number of different agencies involved in an individual's care. In addition, there are often multiple members of the same team involved in an individual's care. During the inquest it became clear that, at times, communication of important issues was not as clear as it should have been . I note that Devon Partnership NHS Trust has significant training available for its staff and other agencies it engages with in relation to patients who are prescribed Clozapine. However, it would be of great assistance to understand what Devon Partnership NHS Trust is doing to ensure that optimum communication of key information is achieved within the community mental health team , and when dealing with its other agencies involved in a patient's care.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely detect Clozapine-associated cardiomyopathies
Wider context from the report “The risk of myocarditis is reasonably well explained in Devon Partnership NHS Trust's policy documentation, but there is less of a focus on cardiomyopathies which would include left ventricular hypertrophy . I understand that the Trust's guidance is based on national guidance. Annual ECGs are required for patients prescribed Clozapine and questions about cardiac function will now be asked at monthly Clozapine clinics. However, I understand that ECGs are not a diagnostic tool used to assist in the diagnosis of cardiomyopathies such as left ventricular hypertrophy and that left ventricular hypertrophy can be asymptomatic. I also understand that an echocardiogram may be able to identify such cardiomyopathies, but that this is not currently required on initiation of Clozapine or routinely at any other time whilst a patient is taking Clozapine .
I am concerned that these cardiomyopathies could therefore go undetected in patients prescribed Clozapine and leave them at unknown increased risk of fatal cardiac arrhythmias, as occurred in William's case. Given that the Trust's guidance is based on national guidance I am concerned this may be a national issue.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Limited provision of Clozapine side-effect and red-flag information to patients attending GP practices
Wider context from the report “Currently around 60% of the cohort of patients prescribed Clozapine who are under the care of Devon Partnership Trust have access to these clinics. The other 40% will attend their GP surgery for their monthly Clozapine phlebotomy service. The phlebotomy service provided at a GP practice is usually an appointment with a non-qualified member of staff, who will not have been specifically trained in the side effects of Clozapine. I am therefore concerned that the level of care provided to patients attending Clozapine clinics on a monthly basis, is likely to be superior to the care provided to those patients who attend their GP practice. In particular, I am concerned that any discussion and repetition of information surrounding red flags and side effects associated with Clozapine, and advice about when to seek medical attention, will be significantly more limited for those patients attending their GP practice than for those attending the monthly Clozapine clinics. I am also concerned that this limitation is likely to extend further than the 40% of patients in receipt of Clozapine under the care of Devon Partnership NHS Trust and that this may be a national issue.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to achieve clear communication of key information with other agencies involved in patient care
Wider context from the report “It is clear that patients suffering with treatment resistant schizophrenia are complex, and as such there are often a number of different agencies involved in an individual's care. In addition, there are often multiple members of the same team involved in an individual's care. During the inquest it became clear that, at times, communication of important issues was not as clear as it should have been . I note that Devon Partnership NHS Trust has significant training available for its staff and other agencies it engages with in relation to patients who are prescribed Clozapine. However, it would be of great assistance to understand what Devon Partnership NHS Trust is doing to ensure that optimum communication of key information is achieved within the community mental health team, and when dealing with its other agencies involved in a patient's care.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a business case to increase resources for dedicated specialist Clozapine clinics across Devon.
Verbatim wording from the response “As a Trust we have developed a business case in order for the organisation to increase resources and to bring all the patients receiving Clozapine onto dedicated Specialist Clozapine clinics across Devon in Barnstaple, Exeter and Torquay (excluding Plymouth where Livewell provide mental health services) to receive the Gold Standard in Physical health monitoring and side effects screening.” Source location Response from Devon Partnership NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish specialist Clozapine clinics providing monthly side-effect screening and patient discussions during phlebotomy appointments.
Verbatim wording from the response “(1) The inquest heard evidence that there should be regular repetition of information to patients suffering from treatment resistant schizophrenia about the risks and red flags associated with the side effects of taking Clozapine. Since William's death Devon Partnership NHS Trust has set up Clozapine clinics which provide the opportunity for staff who are familiar with the side effects associated with Clozapine to discuss these with patients attending for their monthly phlebotomy appointments (required for the purpose of monitoring their white blood cell count).” Source location Response from Devon Partnership NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Bring patients receiving Clozapine under Trust care onto dedicated specialist clinics across Devon, excluding Plymouth.
Verbatim wording from the response “There are around 230 patient that attend the DPT lead specialised Clozapine clinics where physical monitoring and side effects screening occurs in accordance to the regularity of when blood test is required. This varies between weekly, two weekly or every 4 weeks. However, the 40% that accounts for 160 patients that attend GP surgeries where the side effect monitoring and screening does not occur. For this group we will be implementing the following” Source location Response from Devon Partnership NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt SystmOne electronic patient records to enable consent-based information sharing between primary and secondary mental health services.
Verbatim wording from the response “There are a number of steps that Devon Partnership NHS Trust has adopted to ensure effective information sharing between those involved in the care of the patients.” Source location Response from Devon Partnership NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add questions about recent physical illness, palpitations, chest pain, breathlessness and dizziness to monthly Clozapine clinic appointments.
Verbatim wording from the response “At these appointments healthcare professionals will specifically ask patients about their smoking habit, caffeine intake, bowel movements, hypersalivation, sedation, nausea, incontinence, heartburn, infection, and medication changes, in addition to open questions about any other side effects a patient might be experiencing. I am also assured that Devon Partnership NHS Trust will be including additional questions to be discussed at this appointment surrounding recent physical illnesses, palpitations, chest pain, breathlessness and dizziness.” Source location Response from Devon Partnership NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue seeking expert opinions on screening unsuspected patients for Clozapine-associated cardiomyopathy.
Verbatim wording from the response “Following your concerns we have reviewed the evidence based regarding Clozapine physical health monitoring and will be continuing seeking expert opinions as regarding the screening for cardiomyopathy in unsuspected patients to decrease the risk of harm.” Source location Response from Devon Partnership NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine echocardiography is not adopted for Clozapine cardiomyopathy screening because evidence does not support it and its cost is excessive.
Verbatim wording from the response “However the screening for cardiomyopathy for unsuspected patients is significantly difficult. The current evidence based does not support the use of echocardiography as a pre-monitoring requisite given the excessive cost that this will bring. The incidence of cardiomyopathy in people taking Clozapine has been cited as 0.02% of patients in the USA and 0.1% in Australia. This is 1 in 1000 to 1 5000 patients taking Clozapine.” Source location Response from Devon Partnership NHS Trust
Open published response
21 Dec 2023 NICHOLAS JAMES GLAVIND DYMOND · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 2 Failure to ensure independent s.12 doctors have access to patients’ records for Mental Health Act assessments View source Lack of understanding of voluntary admission and the least restrictive option in Mental Health Act assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
NICHOLAS JAMES GLAVIND DYMOND · 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
Nicholas Dymond, who had a history of intermittent drug use, developed paranoia and expressed suicidal thoughts about jumping in front of a train. After a Mental Health Act Assessment following his arrest, he was discharged and ran away when the arranged taxi arrived; less than three hours later, he stepped in front of a train and was pronounced deceased at the scene. The concerns identified included independent doctors potentially conducting assessments without access to patient records and witnesses’ lack of understanding of voluntary admission and the least restrictive option.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure independent s.12 doctors have access to patients’ records for Mental Health Act assessments
Wider context from the report “(1) The inquest heard that independent doctors did not have access to the CareNotes and relied upon printed copies of extracts from the notes which the AMHP considered pertinent to the Mental Health Act Assessment. Training is now available for independent s.12 doctors which, once completed, allows them access to CareNotes, but this training is not a mandated condition of their inclusion on the list of approved s.12 doctors . There remains a risk that, should a Trust doctor not be available to conduct the assessment, an independent doctor with no access to the patient’s records would be called upon to conduct an assessment .
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of voluntary admission and the least restrictive option in Mental Health Act assessments
Wider context from the report “(2) Several witnesses illustrated a lack of understanding of the concept of both a voluntary admission where a patient has undergone a Mental Health Act Assessment and of the ‘least restrictive option’ . The opportunity for a patient to be admitted voluntarily for further assessment and treatment may therefore be missed .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Devon Shared Care Record to facilitate cross-organisational access to clinical records.
Verbatim wording from the response “The “Devon Shared Care Record” is also now being implemented. This will facilitate cross organisational access to clinical care records and so further improve availability of relevant information to clinicians.” Source location Response from Devon Partnership NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide training enabling independent section 12 doctors to access CareNotes.
Verbatim wording from the response “The inquest heard that independent doctors did not have access to the CareNotes and relied upon printed copies of extracts from the notes which the AMHP considered pertinent to the Mental Health Act Assessment. Training is now available for independent s.12 doctors which, once completed, allows them access to CareNotes, but this training is not a mandated condition of their inclusion on the list of approved s.12 doctors. There remains a risk that, should a Trust doctor not be available to conduct the assessment, an independent doctor with no access to the patient’s records would be called upon to conduct an assessment.” Source location Response from Devon Partnership NHS Trust
Open published response
Concerns raised 6 Lack of clarity over the timing of observation chart checks View source Lack of clarity over responsibility for feedback on observation chart problems View source Failure to ensure staff awareness of relevant suicide risk history View source Lack of clarity over responsibility for checking observation charts View source Failure to include historical and contextual risks in risk analysis View source Failure to complete observation charts adequately View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Paul Perrott · 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
Paul Perrott, an inpatient detained under the Mental Health Act, died on 31 July 2020 after attempting to hang himself on Ashcombe Ward. Concerns included inadequate recording of his 15-minute observations, unclear responsibility for checking observation charts, insufficient staff awareness of his recent and historical suicide risk, and a focus on immediate rather than historical and contextual risks.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity over the timing of observation chart checks
Wider context from the report “(2) There appeared to be a lack of clarity over who was responsible for checking the observation charts , when they would be checked by staff over the course of a working day and who would regularly feed back to staff if there was a problem in this respect .
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity over responsibility for feedback on observation chart problems
Wider context from the report “(2) There appeared to be a lack of clarity over who was responsible for checking the observation charts , when they would be checked by staff over the course of a working day and who would regularly feed back to staff if there was a problem in this respect .
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff awareness of relevant suicide risk history
Wider context from the report “(3) At least one member of staff was unaware that Paul had described himself to staff in May 2020 as looking for an opportunity to take his own life if it arose and that Paul had attempted to take his own life less than 3 months previously in exactly the same way as on 31st July 2020 .
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity over responsibility for checking observation charts
Wider context from the report “(2) There appeared to be a lack of clarity over who was responsible for checking the observation charts , when they would be checked by staff over the course of a working day and who would regularly feed back to staff if there was a problem in this respect .
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include historical and contextual risks in risk analysis
Wider context from the report “(4) Although certain changes to policy and procedures were described to me there still seems to be a focus on risk in the “here and now “which does not include an analysis of historical and contextual risks
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete observation charts adequately
Wider context from the report “(1) Paul Perrott’s observations charts were not filled out adequately or at all on the date of his death
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use redesigned patient handover documents to provide ward staff with rapid access to historical risk information, including when patients move wards.
Verbatim wording from the response “The ward handover document has been re-designed. As such, there is a document for each patient which has a photograph of the patient and a section where key historical risk is recorded. This approach makes it possible for a new staff to the ward to have quick access to useful historical risk information during their shifts. This takes into consideration that most patients have lengthy hospital stay with a significant amount of information within the clinical patient record. The handover document is accessible to staff both in hardcopy and electronically. In addition, the new electronic recording platform has been designed in such a way that all clinically relevant risk information are captured on a single domain. This can be updated as new information is received. This is a departure from a system of multiple risk information recording domains.” Source location Response from Devon Partnership NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct monthly senior nurse manager audits of observation completion, submit results to governance, provide feedback, and review performance with ward managers.
Verbatim wording from the response “Policy states that observation audits to check completion of observations are completed monthly by senior nurse managers. This process is in place through the quality review of clinical records and the results of those audits are submitted to the governance manager, feedback to staff and ward governance meetings. The audit performance is then reviewed monthly with ward managers at inpatient governance meetings. Engagement and observation competency checklists are completed for all new staff and these are reviewed and stored by ward managers with the senior nurse manager’s administrator monitoring compliance for wards.” Source location Response from Devon Partnership NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend the observation policy to require shift-by-shift completion checks by the nurse in charge and immediate action on omissions.
Verbatim wording from the response “An amendment to the Trust therapeutic engagement and observation policy has been requested to state that the nurse in charge of each shift is responsible for ensuring completion of observations on a shift by shift basis and taking immediate action where these are not completed. This will go through ratification in January 2024 and has been discussed with the Director and Deputy Director of Nursing.” Source location Response from Devon Partnership NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review inpatient wards' shift-by-shift observation-record initials to check that nurses in charge evidence completion.
Verbatim wording from the response “In addition, the patient observation record has a tick box on each observation sheet where the nurse in charge adds their initials to evidences completion on a shift by shift basis. This has been reviewed on each inpatient ward by the senior nurse manager to check it is being completed by the nurse in charge.” Source location Response from Devon Partnership NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete and electronically share HCR-20 violence-risk assessments for every patient at specified admission intervals.
Verbatim wording from the response “The hospital also employs the use of HCR-20 (Historical Clinical Risk management) tool. This recommended tool is a structured tool to assess the risk of violence and it records historical risk factors in details. The task of completing the HCR-20 document is usually undertaken by the hospital psychology department. The document is presented and shared with members of the Multidisciplinary team after 3 months of admission then every 6 months till a patient is discharged. The HCR-20 assessment is completed for every patient. This is also stored electronically and available to all staff.” Source location Response from Devon Partnership NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss historical and significant risks in daily ward risk meetings and record or share relevant information during ward transfers.
Verbatim wording from the response “Significant and complex risk (or the potential for those risks) should be discussed in a multi-disciplinary team meeting and reviewed at regular intervals until the risk is felt to have reduced. This is regarded as a good practice (4 steps to safety programme). This is already embedded in the hospital. This model acknowledges the dynamic nature of risk and the significance of relevant historical risk factors. In addition, it allows for flexibility in making adjustments to risk management plans.” Source location Response from Devon Partnership NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Capture clinically relevant risk information in a single electronic recording domain that staff can update as information changes.
Verbatim wording from the response “The ward handover document has been re-designed. As such, there is a document for each patient which has a photograph of the patient and a section where key historical risk is recorded. This approach makes it possible for a new staff to the ward to have quick access to useful historical risk information during their shifts. This takes into consideration that most patients have lengthy hospital stay with a significant amount of information within the clinical patient record. The handover document is accessible to staff both in hardcopy and electronically. In addition, the new electronic recording platform has been designed in such a way that all clinically relevant risk information are captured on a single domain. This can be updated as new information is received. This is a departure from a system of multiple risk information recording domains.” Source location Response from Devon Partnership NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing multidisciplinary risk review arrangements address dynamic and relevant historical risk factors.
Verbatim wording from the response “Significant and complex risk (or the potential for those risks) should be discussed in a multi-disciplinary team meeting and reviewed at regular intervals until the risk is felt to have reduced. This is regarded as a good practice (4 steps to safety programme). This is already embedded in the hospital. This model acknowledges the dynamic nature of risk and the significance of relevant historical risk factors. In addition, it allows for flexibility in making adjustments to risk management plans.” Source location Response from Devon Partnership NHS Trust
Open published response
26 Jul 2022 Archi Johnson · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 2 Lack of a system ensuring important information is present on both types of risk assessment View source Failure to clearly record and make relevant previous incidents known to those responsible for care View source
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
Archi Johnson · 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
Archi Johnson, who had a history of depression, self-harm and suicidal ideation, was admitted voluntarily to a hospital ward on 5 November 2019 after reporting intrusive thoughts of taking his own life. He was found hanging on 7 November 2019; concerns were raised that information about a previous similar suicide attempt was not clearly recorded or shared, which may have affected decisions about his risk level, observation level and the removal of potentially dangerous ligature items.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system ensuring important information is present on both types of risk assessment
Wider context from the report “1.Evidence was heard regarding the manner in which information crucial to the
formulation of risk assessments was recorded and shared:
a)Two types of risk assessments were completed, with no system to ensure that important
information is present on both;
b) The previous incident in which Archi had attempted to take his own life in very similar
circumstances on the ward was not clearly entered on the risk assessments used by staff
and therefore not known to a number of those responsible for his care;
c) Those responsible for his care accepted that the above incident was one of which they
would have wanted to have knowledge;
d) The absence of that information may have affected the subsequent decisions made
regarding the setting of risk level, observation level and removal of potentially
dangerous ligature items.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly record and make relevant previous incidents known to those responsible for care
Wider context from the report “1.Evidence was heard regarding the manner in which information crucial to the
formulation of risk assessments was recorded and shared:
a)Two types of risk assessments were completed, with no system to ensure that important
information is present on both;
b) The previous incident in which Archi had attempted to take his own life in very similar
circumstances on the ward was not clearly entered on the risk assessments used by staff
and therefore not known to a number of those responsible for his care;
c) Those responsible for his care accepted that the above incident was one of which they
would have wanted to have knowledge;
d) The absence of that information may have affected the subsequent decisions made
regarding the setting of risk level, observation level and removal of potentially
dangerous ligature items.
” Open source report
Concerns raised 2 Lack of improved communication with Children’s Services during child protection investigations or care proceedings planning View source Failure to provide appropriate support to parents open to DPT services with mental health problems View source
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
Marc David Bennett · 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
Marc David Bennett was distressed by his children being taken into foster care and took his own life at home on 24 May 2020, having fashioned a ligature. The report identified concerns about communication between Devon Partnership Trust staff and Children’s Services during child protection investigations or care proceedings, and about ensuring appropriate support for parents receiving mental health services.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of improved communication with Children’s Services during child protection investigations or care proceedings planning
Wider context from the report “Lessons learned and submitted in the report by Devon Partnership Trust were, there is a need to ensure improved communication by DPT staff with Children’s Services when children are undergoing S47 Child Protection investigations, and/or planning is taking place for care proceedings , to ensure appropriate support to parents open to DPT services with mental health problems
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate support to parents open to DPT services with mental health problems
Wider context from the report “Lessons learned and submitted in the report by Devon Partnership Trust were, there is a need to ensure improved communication by DPT staff with Children’s Services when children are undergoing S47 Child Protection investigations, and/or planning is taking place for care proceedings, to ensure appropriate support to parents open to DPT services with mental health problems
” Open source report
Concerns raised 1 Failure to physically inspect accommodation suitability before placement View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Glenn Macmartin · 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
Glenn Macmartin had Bipolar Disorder and an Acquired Brain Injury and required specific care and accommodation. He was placed in a privately owned care home, where concerns were raised about care and suboptimal note keeping; the home later closed. He was admitted to hospital and died there on 1 April 2019.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to physically inspect accommodation suitability before placement
Wider context from the report “(1) The deceased was accommodated in a Care Home that was subsequently formally closed due to poor service.
The selection of the accommodation was made without a physical inspection of its suitability for the deceased by the organisation with responsibility for providing the accommodation before the deceased took up residence.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an out-of-area placement protocol and provider monitoring form covering suitability assurances and face-to-face reviews.
Verbatim wording from the response “• A protocol to specifically address the placing of people outside of the Trust’s geographical area has been developed. This will strengthen our existing practice by providing a clear guide for our teams and follows the guidance within the advice note for directors and of adult social services commissioning out of area care and support services produced by ADASS. It also highlights the need to ensure the provider has arrangements in place and contains provisions to assure of suitability of service and face to face reviews. The Trust has also developed an Out of County Care Provider Monitoring form as part of its provider assurance service. I attach the protocol and Monitoring form for your information.” Source location Response-from-Wonford-House-Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Link community and forensic social work teams to standardise placement sourcing and review and ensure proposed placements reach the contract and review team before contracting.
Verbatim wording from the response “• The community social work managers have linked with the forensic social work team at Langdon Hospital (a secure service for which the Trust is responsible, and where Mr MacMartin had been detained) to strengthen links and ensure that processes and practice relating to the sourcing and review of social care is uniform across all services and that the contract and review team are fully cited on all proposed placements prior to any contracting taking place;” Source location Response-from-Wonford-House-Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a social care delivery redesign with dedicated community mental health social workers responsible for sourcing and reviewing placements.
Verbatim wording from the response “• A redesign of social care delivery within the Trust is now complete, with dedicated social workers in each community mental health team, who are responsible for both the sourcing and review of social care placements and support;” Source location Response-from-Wonford-House-Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inspect new provider facilities before contracting to assure placement suitability.
Verbatim wording from the response “In line with the evidence set given by ████████ at the Inquest, in the time since Mr MacMartin’s death, a decision has been made that mental health social care will not contract with new providers without visiting the facilities to gain assurance of suitability.” Source location Response-from-Wonford-House-Hospital
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing CQC ratings, contractual quality provisions and placement experience were considered sufficient assurance that the care home was appropriate.
Verbatim wording from the response “The Trust does reasonably rely on the inspections and ratings provided by the CQC in terms of quality assurance and adherence to any relevant regulations. I understand that at the time of Mr MacMartin’s placement at Annette’s Care Home (“the Care Home”) in Plymouth the corresponding CQC report was reviewed. It was confirmed that the Care Home was rated by the CQC as “Good”. Furthermore, at the time Devon County Council had an existing contract in place with the Care Home. The contract for services entered into included the following provisions around quality assurance:” Source location Response-from-Wonford-House-Hospital
Open published response
Concerns raised 1 Failure to complete risk assessments for patients going on leave that identify community risks and agreed staff actions in case of plan breakdown View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Benjamin Popavach · 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
Benjamin Popavach was a voluntary patient on home leave from a mental health unit, could not be contacted by medical staff, and was subsequently found in the sea off Corbyn Head, Torquay. The report identifies concerns about completing risk assessments for patients going on leave, including community risks and actions if plans break down, and sharing this learning with ward staff and community teams.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete risk assessments for patients going on leave that identify community risks and agreed staff actions in case of plan breakdown
Wider context from the report “(2) At Page 20 of the Root Cause Analysis there is an outcome of the review listed under
Immediate Changes – Ensure risk assessments are completed for patients going on leave, which identify risks in the community and agreed actions to be taken by staff in case of a breakdown in plan
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete leave risk assessments identifying community risks and agreed staff actions if the plan breaks down.
Verbatim wording from the response “Immediate changes | Ensure risk assessments are completed for patients going on leave, which identify risks in the community and agreed actions to be taken by staff in case of a breakdown in a plan.
Sharing the learning | To be shared with ward staff and community teams” Source location 2020-0214-Response-from-Devon-Partnership-NHS-Trust-Redacted.pdf
Open published response
23 Mar 2020 Lewis Charles Francis · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 2 Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum View source Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment View source
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
Lewis Charles Francis · 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
Lewis Charles Francis was arrested after stabbing his mother while acutely psychotic and was remanded to HM Prison Exeter after no ready medium secure mental health hospital transfer facility was available. He died at the prison on 24 April 2017 by suicide as a result of suspension by a ligature. Concerns included the lack of a ready transfer mechanism from police custody to medium secure mental health facilities, and insufficient understanding of the needs and vulnerabilities of prisoners on the autistic spectrum.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum
Wider context from the report “(2) Evidence at the inquest suggested that there was an insufficient understanding of the special needs and vulnerabilities of those prisoners who are within the autistic spectrum
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment
Wider context from the report “(1) At present there is no mechanism for the ready transfer of a person in police custody within the police areas of Devon and Cornwall, Avon and Somerset, Wiltshire and Gloucestershire from police custody to a medium secure mental health facility for assessment / treatment under sections 2 and 3 of the Mental Health Act 1983 where such a person is suspected of or charged with a serious crime. Such an arrangement exists in the West Midlands where a Memorandum of Understanding has been developed and agreed between relevant agencies.
” Open source report
27 Feb 2018 David John Ireland · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 1 Failure to advise about emergency department presentation when mental health crisis concerns continue View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David John Ireland · 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
David John Ireland experienced an acute-onset psychosis, forced entry into a house, climbed from a first-floor window while detained by residents, and sustained serious injuries in the fall. He died shortly after admission to hospital; a concern was raised that the crisis team did not advise him or his friend that he could attend the emergency department for an urgent mental health assessment.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to advise about emergency department presentation when mental health crisis concerns continue
Wider context from the report “(1) Contact was made by Mr Ireland’s friend on the day of his death with the crisis team. Mr Ireland also spoke with them during the same telephone contact call. No advice was given that Mr Ireland could present at the emergency department should concerns continue about his mental health crisis.
Had such advice been given it may have impacted on the course of events and facilitated an urgent mental health assessment. This opportunity was lost as Mr Ireland was not able to make any such decision and his friend was unaware that this was an option available with sudden onset mental health symptoms.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review relevant answer-machine messages and add references to all appropriate sources of further support.
Verbatim wording from the response “We have asked the relevant teams to review any answer machine messages they use and include appropriate reference to all sources of further support.” Source location 2018-0057-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include advice about giving options for further support in local induction for temporary workers in the relevant teams.
Verbatim wording from the response “We will be including the need to give this advice in our local induction for temporary workers (agency staff) within these teams.” Source location 2018-0057-Response-by-Devon-Partnership-NHS-Trust
Open published response
26 Feb 2018 Naomi Clare Sourbut · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 2 Failure to put protective factors in place for individuals with self-harm intent and access to the means View source Failure to ensure consideration and implementation of root cause analysis recommendations View source
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
Naomi Clare Sourbut · 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
Naomi Clare Sourbut, who had a history of anxiety, depression, self-harm and bulimia, self-administered an overdose of medication, most probably Venlafaxine, and died after developing hypoxic brain injury. Concerns included whether recommendations from a root cause analysis had been considered and implemented, and whether protective factors were put in place after she reported suicidal intent and access to medication.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to put protective factors in place for individuals with self-harm intent and access to the means
Wider context from the report “(2) In addition where an individual has indicated an intent to cause themselves harm and have advised clinicians they have access to the means to cause that harm then protective factors should be put in place to help reduce the risk of the individual harming themselves in the way they have indicated or otherwise.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure consideration and implementation of root cause analysis recommendations
Wider context from the report “(1) A root cause analysis investigation was undertaken by the Devon Partnership Trust and that report was finalised on the 8th September 2017. The report contained a number of identified lessons learned and recommendations, ten in total (see attached annexe), applicable to different teams within Devon Partnership Trust.
It was unclear at the Inquest as to whether or not these recommendations have been considered and acted upon by the teams to which they were directed particularly where clients have talked of suicidal ideation and identified the means with which to bring about their death.
In my opinion action should be taken to prevent future deaths and I believe you and your organisation has to take such action to confirm the recommendations in the root cause analysis report File No: 2017/10523 NON ANON RCA JHNS 18.9.17 – having been considered and implemented .
” Open source report
4 Aug 2017 Carly Marie GORDON · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 2 Failure to review patients receiving extended-term medication for suitability of continued long-term use View source Failure to prescribe longer-acting rather than shorter-acting benzodiazepines for long-term use View source
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 Partnership NHS Trust; 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 Partnership NHS Trust; 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
14 Feb 2017 Wendy Louise Telfer · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 4 Lack of available psychiatric inpatient beds View source Failure to correctly apply the Mental Health Act in physical care environments View source Delays in discharge caused by inadequate social and community care resources View source Lack of adequate mental health training for physical healthcare staff View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Wendy Louise Telfer · 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
Wendy Louise Telfer died on 20 March 2016 in hospital from an overdose of purchased non-prescribed medication taken five days earlier; the medical cause of death was recorded as liver failure due to paracetamol overdose, with asthma also recorded. The report identified concerns about missed opportunities to keep Wendy safe, confusion about applying the Mental Health Act in a physical care setting, and the lack of an available psychiatric inpatient bed.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of available psychiatric inpatient beds
Wider context from the report “(2) Wendy was to be admitted to a psychiatric bed at one stage of this final hospital stay, but she could not be transferred immediately due to the lack of beds . The Devon Partnership Trust was candid and open regarding their considerable difficulties in this regard, that have been worsening over a number of years. Currently the Court was advised that a block booking of beds has been secured in the North Somerset region, but this short term solution is financially unsustainable, and not a good solution in term of patient need and geographical location. It is accepted that the problem of psychiatric in-patient beds is a national one , but on this occasion, had a bed been available when needed for Wendy, her death is likely to have been avoided.
The Court was advised that much of the difficulty is delayed discharge of patients, and it is acknowledged that this is a wider issue of social and community care and resources. This report is therefore being copied to the commissioners as well for their further consideration of the current untenable situation.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly apply the Mental Health Act in physical care environments
Wider context from the report “(1) It was recognised at inquest that there is a frequent need for patients with significant mental health needs to increasingly be cared for in a physical care environment, due to concurrent physical and mental health needs, and due to an increasing difficulty in sourcing psychiatric beds, which often requires a wait on a general ward. It was also acknowledged that the training of the physical healthcare staff "needs to improve", although it must be said that efforts have been made and are continuing to address this issue.
From the evidence there was clear confusion regarding the application of the Mental Health Act in the physical care environment , which led in this case to Wendy being allowed to leave the ward unaccompanied and without transport, which could have been avoided with better understanding of the available restrictive legislation.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in discharge caused by inadequate social and community care resources
Wider context from the report “(2) Wendy was to be admitted to a psychiatric bed at one stage of this final hospital stay, but she could not be transferred immediately due to the lack of beds. The Devon Partnership Trust was candid and open regarding their considerable difficulties in this regard, that have been worsening over a number of years. Currently the Court was advised that a block booking of beds has been secured in the North Somerset region, but this short term solution is financially unsustainable, and not a good solution in term of patient need and geographical location. It is accepted that the problem of psychiatric in-patient beds is a national one, but on this occasion, had a bed been available when needed for Wendy, her death is likely to have been avoided.
The Court was advised that much of the difficulty is delayed discharge of patients , and it is acknowledged that this is a wider issue of social and community care and resources . This report is therefore being copied to the commissioners as well for their further consideration of the current untenable situation.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate mental health training for physical healthcare staff
Wider context from the report “(1) It was recognised at inquest that there is a frequent need for patients with significant mental health needs to increasingly be cared for in a physical care environment, due to concurrent physical and mental health needs, and due to an increasing difficulty in sourcing psychiatric beds, which often requires a wait on a general ward. It was also acknowledged that the training of the physical healthcare staff "needs to improve" , although it must be said that efforts have been made and are continuing to address this issue.
From the evidence there was clear confusion regarding the application of the Mental Health Act in the physical care environment, which led in this case to Wendy being allowed to leave the ward unaccompanied and without transport, which could have been avoided with better understanding of the available restrictive legislation.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise inpatient bed-capacity and patient-safety risks with commissioners through contract monitoring and formal Board-level correspondence.
Verbatim wording from the response “The Trust is acutely aware of the pressure upon our available bed stock and has raised the issue with our commissioners through both our contract monitoring meetings and via a formal letter from our Board level clinicians highlighting the very real risk to patient safety.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Secure temporary additional contracted out-of-area bed capacity.
Verbatim wording from the response “We now have in place a central trust wide bed management team to proactively manage and secure beds for those in need as quickly as we possibly can. We have temporarily secured additional contracted bed capacity out of area to help meet demand as of Monday 20 March 2017 rather than rely on ad hoc arrangements as we are in competition with other NHS providers for private beds.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a central Trust-wide bed-management team to proactively manage and secure beds.
Verbatim wording from the response “We now have in place a central trust wide bed management team to proactively manage and secure beds for those in need as quickly as we possibly can. We have temporarily secured additional contracted bed capacity out of area to help meet demand as of Monday 20 March 2017 rather than rely on ad hoc arrangements as we are in competition with other NHS providers for private beds.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver recurring Liaison Psychiatry training to general-hospital staff, including Emergency Department, site-management, medical-staff, foundation-doctor and Mental Health Champion sessions.
Verbatim wording from the response “As described by our Liaison Psychiatry Clinical Team Leader during the inquest we have continued to support the training of the staff within the RD&E, I have described below the general role of the Liaison Psychiatry Team in training and the specific work undertaken during the last year.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the newly developed challenging-behaviour and rapid-tranquilisation training package monthly.
Verbatim wording from the response “• A full day package has just been developed called ‘Management of Challenging Behaviour – Rapid Tranquilisation - a last resort!’ and this began monthly roll-out in March 2017, this refers to use of the MHA and Mental Capacity Act in its content.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Extend Crisis Resolution and Home Treatment team operating hours to midnight, seven days a week.
Verbatim wording from the response “We have agreed a plan of work internally to improve the capacity of our Crisis Resolution and Home Treatment teams and they have now extended their operational times to midnight 7 days per week with a view to supporting more people at home and facilitating early discharge from our inpatient wards. We have also agreed with both Devon County Council and both of our CCGs to take responsibility for and to streamline the current application and review process for both social and continuing health care funding which significantly adds to the length of time a person stays in hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop further alternatives to acute admission, including improved community support and additional step-down provision.
Verbatim wording from the response “We have also used spare capacity in one of our recovery/rehabilitation wards to provide step down care for those people no longer requiring acute inpatient care on a temporary basis while we work on providing further alternatives to admission including possible crisis houses, a purpose commissioned step down facility and looking at how we may better support people with certain conditions in the community rather than admitting to hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agree responsibility for streamlining social-care and continuing-healthcare funding applications and reviews.
Verbatim wording from the response “We have agreed a plan of work internally to improve the capacity of our Crisis Resolution and Home Treatment teams and they have now extended their operational times to midnight 7 days per week with a view to supporting more people at home and facilitating early discharge from our inpatient wards. We have also agreed with both Devon County Council and both of our CCGs to take responsibility for and to streamline the current application and review process for both social and continuing health care funding which significantly adds to the length of time a person stays in hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate an embedded system directing Mental Health Act issues to site managers and provide rolling training for the site-management rota.
Verbatim wording from the response “We agreed that wider training across the hospital for nurses and medical staff was unrealistic given that the majority of staff would only come into contact with the Act infrequently, we agreed that all the training and expertise would be held by the site management team and our MHA office and liaison team regularly meet the site manager to discuss incidents, share learning, update in relation to any amendments to the Act and deliver rolling training to the site managers who run a 24 hour, 7 day a week rota across the whole hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide temporary step-down care using spare recovery and rehabilitation ward capacity.
Verbatim wording from the response “We have also used spare capacity in one of our recovery/rehabilitation wards to provide step down care for those people no longer requiring acute inpatient care on a temporary basis while we work on providing further alternatives to admission including possible crisis houses, a purpose commissioned step down facility and looking at how we may better support people with certain conditions in the community rather than admitting to hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Financial pressures and reduced staff availability constrain the Trust's ability to secure additional inpatient capacity.
Verbatim wording from the response “I think it is important to note that securing additional capacity is compounded by both the ever tightening financial position of our commissioners, ourselves and the reducing availability of staff across the country. I would very much like to assure you that we as a Trust are doing everything we can to use our available resources in the most efficient way we can to meet the increasing demand we are facing. I would also like to assure you that we will always put the safety of our patients first and will continue to do our level best to ensure someone needing a bed is provided with one as soon as we are able to source either internally or externally via the private sector.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Wider Mental Health Act training for hospital staff is considered unrealistic because most staff encounter the Act infrequently.
Verbatim wording from the response “We agreed that wider training across the hospital for nurses and medical staff was unrealistic given that the majority of staff would only come into contact with the Act infrequently, we agreed that all the training and expertise would be held by the site management team and our MHA office and liaison team regularly meet the site manager to discuss incidents, share learning, update in relation to any amendments to the Act and deliver rolling training to the site managers who run a 24 hour, 7 day a week rota across the whole hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mental Health Act expertise is held centrally, with site-manager training and liaison support considered an effective hospital-wide arrangement.
Verbatim wording from the response “We agreed that wider training across the hospital for nurses and medical staff was unrealistic given that the majority of staff would only come into contact with the Act infrequently, we agreed that all the training and expertise would be held by the site management team and our MHA office and liaison team regularly meet the site manager to discuss incidents, share learning, update in relation to any amendments to the Act and deliver rolling training to the site managers who run a 24 hour, 7 day a week rota across the whole hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
Open published response
25 Oct 2016 Matthew Llewellyn-Jones · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 4 Failure of the admission recording system to make obtaining carer and family information mandatory View source Failure to secure the ward door View source Failure of ward policy to require unpredictable and irregular observations View source Failure to provide clear and consistently reinforced observation training and instruction View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Matthew Llewellyn-Jones · 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
Matthew Llewellyn-Jones, who had been detained under section 2 of the Mental Health Act after becoming acutely unwell with psychosis, left a locked hospital ward unaccompanied and was later found hanging by a ligature in the hospital grounds. The concerns included breaches of the ward’s locked door, predictable observations, inadequate collection of information from family and carers, insufficient assessment and observation, inadequate staff induction, and staffing levels that contributed to failings in his care and security.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the admission recording system to make obtaining carer and family information mandatory
Wider context from the report “(3) A new system of note recording has been introduced since this death, but it still does not make obtaining information from carers and/or family mandatory on admission . The importance of this information was readily acknowledged by the Trust in their internal inquiry and at inquest . The electronic recording system should be able to facilitate capturing such information with the use of mandatory fields to avoid this oversight and could assist the Trust in achieving their stated aims in this respect.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to secure the ward door
Wider context from the report “(1) The Devon Partnership trust acknowledged in inquest that the "locked door" is still being breached on occasion , as identified on audit. An electronic pad or sign has been considered to offer clearer indications of when the door should be secured, but not yet trialled or actioned. The door therefore remains an ongoing security risk for the ward .
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ward policy to require unpredictable and irregular observations
Wider context from the report “(2) Observations when carried out in the context of a secure mental health environment should not be predictable or entirely regular. This is not currently part of the ward policy , although it appeared to be accepted by senior staff at inquest. The Trust should consider further measures to ensure that training and instruction given to all staff in relation to observations is clear, constantly reinforced, and in line with best practise.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear and consistently reinforced observation training and instruction
Wider context from the report “(2) Observations when carried out in the context of a secure mental health environment should not be predictable or entirely regular. This is not currently part of the ward policy, although it appeared to be accepted by senior staff at inquest. The Trust should consider further measures to ensure that training and instruction given to all staff in relation to observations is clear, constantly reinforced, and in line with best practise .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Activate a Care Notes risk-assessment area recording carers’ and family members’ views.
Verbatim wording from the response “• Risk Assessment (Specific area looking at carer/family views) – this is due to become active by the end of January 2017 (ref 2.2)” Source location 2016-0385-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use an active Care Notes care-planning field to record information sought from carers or family.
Verbatim wording from the response “A copy of the Care Notes forms are attached, the specific changes that have been made are-” Source location 2016-0385-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain locked Cedars doors, warning signage, admission information and supportive engagement procedures before patients leave.
Verbatim wording from the response “• The doors at the Cedars have been ‘locked’ since the inquest. Review continues as outlined in the Entry and Exit policy. Entrances to our in-patient units have notification that the door is locked. Patients are informed of the locked door position on admission and the process of supportive engagement prior to leave.” Source location 2016-0385-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Finalize and implement revised Engagement Policy requirements for documenting and varying intermittent engagement and observation intervals.
Verbatim wording from the response “The ‘Engagement Policy’ has been reviewed by the Deputy Director of Nursing and is currently being finalised, it has been changed to include the following -” Source location 2016-0385-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and revise the Entry and Exit Policy to support locked doors across inpatient units while protecting patients’ rights to exit.
Verbatim wording from the response “• The locked door and permanently locking has been discussed at our Senior Management Board and it has been agreed that the Entry and Exit Policy is reviewed with a recommendation for locked doors on all of our in-patient units.” Source location 2016-0385-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A mandatory field for carer and family information will not be added; free-text recording and audit follow-up are considered sufficient.
Verbatim wording from the response “The introduction of a mandatory field has been considered by the Care Notes team and senior clinical colleagues. The decision has been made not to add as a mandatory field, it will continue to be recorded as a ‘free text’ field. The rational for this decision is that a mandatory field could be completed with a generic comment for example ‘have been unable to contact family at this time’, when audited as detailed below, this would be identified as completed. If the field is left ‘blank’ the audit will highlight this and allow individual review and follow up with the staff member concerned.” Source location 2016-0385-Response-by-Devon-Partnership-NHS-Trust
Open published response
7 Sep 2016 Louise Turner · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 6 Inadequate staff training on responsibility for patient contact View source Failure to ensure staff-led contact for patients with severe mental health conditions View source Lack of adequate post-discharge mental health care and contact View source Failure of effective and robust duty system arrangements View source Failure of an effective and robust buddying system View source Unavailability of female psychiatric intensive care beds in Devon View source See 3 more concerns
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
Louise Turner · 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
Louise Turner died on 27 June 2014 from inhalation of helium after recently being discharged from a lengthy inpatient stay while receiving treatment for a serious mental health illness. The report raised concerns about inadequate post-discharge care and contact, ineffective duty and buddying arrangements, expectations that patients initiate contact, and the absence of female intensive psychiatric care beds in Devon.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training on responsibility for patient contact
Wider context from the report “(3) There was a suggestion at Inquest that the patients themselves were expected to be in charge of making contact. In cases of severe mental health, this does not appear to be appropriate or realistic, and the Devon Partnership Trust should reconsider this and/or the training of their staff who hold this belief .
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff-led contact for patients with severe mental health conditions
Wider context from the report “(3) There was a suggestion at Inquest that the patients themselves were expected to be in charge of making contact . In cases of severe mental health, this does not appear to be appropriate or realistic , and the Devon Partnership Trust should reconsider this and/or the training of their staff who hold this belief.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate post-discharge mental health care and contact
Wider context from the report “(1) The Devon Partnership trust had no adequate mental health care for Louise after she was discharged . There was inadequate contact and no explanation at Inquest as to why this had not taken place.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of effective and robust duty system arrangements
Wider context from the report “(2) The duty system arrangements and buddying system referred to at Inquest were not effective or robust and need to be reconsidered in the light of the outcome of this case.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of an effective and robust buddying system
Wider context from the report “(2) The duty system arrangements and buddying system referred to at Inquest were not effective or robust and need to be reconsidered in the light of the outcome of this case.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of female psychiatric intensive care beds in Devon
Wider context from the report “(4) There are no female intensive care beds for psychiatric patients in Devon . This does not match the desired parity of mental health care with physical health care. Devon Partnership Trust needs to consider future planning and provision to ensure the needs of patients can be met.
” Open source report
14 Dec 2015 William Jeffrey MASKELL · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 3 Insufficient capacity for timeous intervention for students in distress View source Failure to prioritise welfare over student privacy in urgent intervention decisions View source Lack of a clear protocol for agency and police involvement View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
William Jeffrey MASKELL · 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
William Jeffrey MASKELL, who had Bipolar Disorder, was found collapsed in his university room after ingesting a fatal quantity of Venlafaxine and Lamotrigine. He was taken to hospital but was declared deceased. Concerns included the lack of a clear protocol for involving relevant agencies and the Police, delays in attending and forcing entry, and a risk of future deaths from untimely intervention.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity for timeous intervention for students in distress
Wider context from the report “3. There is a real risk of future deaths of students in distress for lack of timeous intervention because of the current restraints .
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise welfare over student privacy in urgent intervention decisions
Wider context from the report “2. The respect for the autonomy of the student in running his/her private life appeared to take precedence over a real concern for welfare , resulting in delays in attendance at the scene and a reluctance to take the decision to force entry .
It appears that the Students Union’s opposition to any erosion of the students’ human rights (to privacy) was a factor.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear protocol for agency and police involvement
Wider context from the report “1. The decision to go to William’s room was hampered by the lack of a clear protocol for the involvement of the relevant agencies and the Police .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the university to develop a procedure for consulting statutory bodies about unconfirmed, non-high-risk deterioration in student mental health or wellbeing.
Verbatim wording from the response “The Trust has had further discussions with the University with a view to identifying specific action that can be taken to improve the joint working between us; we have nominated our Adult Directorate Practice Lead for the Community to work with colleagues from the University to progress the following actions:” Source location William-Maskell-Response2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider developing jointly agreed, student-specific contingency plans covering responses, roles and accommodation access during deterioration in mental health or wellbeing.
Verbatim wording from the response “The Trust has had further discussions with the University with a view to identifying specific action that can be taken to improve the joint working between us; we have nominated our Adult Directorate Practice Lead for the Community to work with colleagues from the University to progress the following actions:” Source location William-Maskell-Response2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain university room-access information and ensure STEP and CRISIS staff can accurately advise wellbeing staff and signpost appropriate agencies.
Verbatim wording from the response “The Trust has had further discussions with the University with a view to identifying specific action that can be taken to improve the joint working between us; we have nominated our Adult Directorate Practice Lead for the Community to work with colleagues from the University to progress the following actions:” Source location William-Maskell-Response2
Open published response
22 Oct 2015 Diane Knight · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 2 Failure of door privacy arrangements to prevent concealment of patient self-harm attempts View source Failure of door privacy arrangements to maintain staff visibility of patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Diane Knight · 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
Diane Knight, who had a significant history of mental illness and previous attempts to end her life by drug overdose, died by hanging on 3 February 2015 while a voluntary patient at Ocean View Ward, North Devon District Hospital. A towel placed over her room door and window concealed a belt end secured against the door jamb, and concerns were raised that this practice could conceal self-harm attempts and prevent staff from properly monitoring patients.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of door privacy arrangements to prevent concealment of patient self-harm attempts
Wider context from the report “(1) The continued practice of putting a towel over the door could hide an attempt by a patient to harm themselves or end their life such as here with a belt end being trapped by the door against the door jamb .
(2) The continuation of this practice may prevent staff being properly able to monitor the patients on the Unit, therefore this practice should be reviewed.
(3) An alternative method for preserving patient privacy should be considered that would not allow a patient to conceal an attempt to cause themselves harm .
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of door privacy arrangements to maintain staff visibility of patients
Wider context from the report “(1) The continued practice of putting a towel over the door could hide an attempt by a patient to harm themselves or end their life such as here with a belt end being trapped by the door against the door jamb.
(2) The continuation of this practice may prevent staff being properly able to monitor the patients on the Unit , therefore this practice should be reviewed.
(3) An alternative method for preserving patient privacy should be considered that would not allow a patient to conceal an attempt to cause themselves harm.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discontinue covering bedroom observation windows with towels or similar items across inpatient areas.
Verbatim wording from the response “(1) The practice of patients obscuring/covering the glass windows in their bedroom doors will be discontinued across all inpatient areas within Devon Partnership NHS Trust. A patient safety alert will be issued highlighting the risks and the actions required to be taken to eradicate this risk.” Source location Diane-Knight-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and distribute a trust-wide safety briefing requiring immediate action to prevent bedroom-window coverings from obstructing patient observation.
Verbatim wording from the response “A trust wide safety briefing has been produced and was published on our Trust intranet, this is accessible to all staff and is one of the ways in which we publish and share learning across our services. This briefing was also included in our ‘on-line news’ which is sent out by email to all staff.” Source location Diane-Knight-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a further local alert to inpatient units and obtain formal ward responses confirming review and appropriate action.
Verbatim wording from the response “We plan to issue a further local alert to all inpatient units which will be sent using our alerts process; this requires a formal response from each ward confirming that the alert has been reviewed and appropriate action taken. This is going to be sent once the RCA report has been agreed so any further actions from the commissioner’s review can be included. This is due to be completed by the end of January 2016 (following agreement of the report by the commissioner).” Source location Diane-Knight-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and complete a Respect and Dignity Audit requiring teams to consider safe ways to maintain privacy.
Verbatim wording from the response “We are in the process of developing our Respect and Dignity Audit; we will be including a specific requirement for teams to consider how they maintain privacy in these types of situation and what more can be done to keep patients safe whilst maintaining their privacy. This audit will then inform any wider actions needed. The audit is due to be completed by the end of January 2016.” Source location Diane-Knight-Response
Open published response
15 Jan 2015 Judith Anne SAVILLE · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 4 Failure to implement the action plan arising from the Root Cause Analysis View source Failure to limit medication supplies for patients with a history of prescribed-medication overdose View source Lack of a computer-system warning for patients with a history of overdose View source Failure to audit the effectiveness of the action plan View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Judith Anne SAVILLE · 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
Judith Anne Saville, who had a long history of agitated depression and previous psychiatric admissions and ECT treatment, was found deceased at home on 28 January 2014. The inquest concluded that she died from a Zopiclone and Paracetamol overdose and that she had taken her own life. Concerns included the quantity of medication prescribed, the need for warnings about a history of overdose in the practice’s computer system, and implementation and auditing of an action plan.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement the action plan arising from the Root Cause Analysis
Wider context from the report “(2) For the attention of Melanie Walker
The Inquest heard evidence from ████████████████████ who had conducted a Root Cause Analysis into the circumstances of Mrs Saville’s death. A copy of that Report is attached.
████████ gave evidence that there were a number of lessons to be learned and that an action plan had been drafted .
At Inquest I expressed my concern that the action plan was implemented and its effectiveness subsequently audited.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to limit medication supplies for patients with a history of prescribed-medication overdose
Wider context from the report “(1) For the attention of ████████
In his evidence ████████ told the Court that Mrs Saville’s death had been reviewed at a significant events meeting in his practice. I was told that it was felt he had prescribed too much medication, particularly as the person who had a past medical history that included overdoses of prescribed medication . ████████ said that there was now an increased awareness on the Practitioners not to prescribe so much medication in similar circumstances . He felt that a supply of no more than a week’s worth of medication would be appropriate .
████████ said that the system could be made more robust by introducing a warning on the firm’s computer system. This would assist Practitioners by drawing to their attention a past medical history of overdose. It was felt that this may particularly be of benefit to locum doctors who would not necessarily have the same recall of a patient as a partner in the practice.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a computer-system warning for patients with a history of overdose
Wider context from the report “(1) For the attention of ████████
In his evidence ████████ told the Court that Mrs Saville’s death had been reviewed at a significant events meeting in his practice. I was told that it was felt he had prescribed too much medication, particularly as the person who had a past medical history that included overdoses of prescribed medication. ████████ said that there was now an increased awareness on the Practitioners not to prescribe so much medication in similar circumstances. He felt that a supply of no more than a week’s worth of medication would be appropriate.
████████ said that the system could be made more robust by introducing a warning on the firm’s computer system . This would assist Practitioners by drawing to their attention a past medical history of overdose . It was felt that this may particularly be of benefit to locum doctors who would not necessarily have the same recall of a patient as a partner in the practice .
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to audit the effectiveness of the action plan
Wider context from the report “(2) For the attention of Melanie Walker
The Inquest heard evidence from ████████████████████ who had conducted a Root Cause Analysis into the circumstances of Mrs Saville’s death. A copy of that Report is attached.
████████ gave evidence that there were a number of lessons to be learned and that an action plan had been drafted.
At Inquest I expressed my concern that the action plan was implemented and its effectiveness subsequently audited .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reassess CRHT patients before discharge when increased risks have been identified.
Verbatim wording from the response “Action 2
Recommendation: That the CRHT team reassess individuals prior to discharge where increased risks have been highlighted.” Source location 2015-0011-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Document discharge awareness and routinely consult and inform people and carers about CRHT discharge decisions.
Verbatim wording from the response “Action 4
Recommendation: That RiO notes and recovery plans regarding the discharge of people from the CRHT team clearly state whether the person involved and their carers are aware of the discharge.” Source location 2015-0011-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have CRHT staff attend weekly Rougemont discharge-planning meetings to improve Adult/OPMH communication.
Verbatim wording from the response “Action 6
Recommendation: That the OPMH team and the CRHT team carry out a review of how to improve communication between teams with recommendations and actions reported into the CRHT team and OPMH team.” Source location 2015-0011-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record all telephone calls received by CRHT teams in clinical records.
Verbatim wording from the response “Action 3
Recommendation: That all phone calls received by CRHT teams are recorded in the clinical record.” Source location 2015-0011-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase OPMH consultant input and provide CRHT teams with direct access to OPMH consultants or named backup.
Verbatim wording from the response “Action 6
Recommendation: That the OPMH team and the CRHT team carry out a review of how to improve communication between teams with recommendations and actions reported into the CRHT team and OPMH team.” Source location 2015-0011-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Register both CRHT teams for the Triangle of Care initiative.
Verbatim wording from the response “Action to address recommendation: That the CRHT team CTL communicates the importance of the clinical record indicating that people using the service and their carers are aware of discharge. That carers are being informed about discharge by both CRHT being signed up to the Triangle of Care initiative and is also monitored by CRSM/random audits.” Source location 2015-0011-Response-by-Devon-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop recovery plans face to face with people using CRHT services whenever safe and practicable.
Verbatim wording from the response “Action 7
Recommendation: That all cases open to the CRHT team have a recovery plan that is developed face to face with the individual.” Source location 2015-0011-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider the wishes and opinions of people receiving services in clinical decision making.
Verbatim wording from the response “Action 8
Recommendation: That the wishes and opinions of people receiving services are always considered in the clinical decision-making process.” Source location 2015-0011-Response-by-Devon-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide comprehensive assessments and formulate recovery, care and risk plans for people using CRHT services.
Verbatim wording from the response “Action 1
Recommendation: That Crisis Teams should provide a comprehensive assessment (including a full mental state assessment) for all people using the service, required for the recovery plan. From this a recovery / care plan and risk assessment (including information of known risks) should be formulated to meet and manage identified needs and risks.” Source location 2015-0011-Response-by-Devon-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact people on the day they are discharged from CRHT, using face-to-face or telephone contact according to risk.
Verbatim wording from the response “Action 5
Recommendation: That, unless clinically indicated otherwise, the CRHT team always contact people (face to face or telephone) on the day that they are discharged from the team.” Source location 2015-0011-Response-by-Devon-Partnership-NHS-Trust
Open published response
28 Oct 2014 Polly Elisabeth Jane CARPENTER · Prevention of Future Deaths report Exeter & Great Devon
View report summary
Concerns raised 6 Staff lack of knowledge of current patient risk levels View source Failure to record risk assessments on RIO View source Failure to maintain a permanent record of nursing tasks performed View source Failure to formally record observation levels View source Failure to record nurse allocation for observations View source Nebulous execution of the named nurse system View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Polly Elisabeth Jane CARPENTER · 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
Polly Elisabeth Jane Carpenter, who had a history of psychotic depression and repeated suicide attempts, left an inpatient psychiatric unit on 5 May 2011 and deliberately sat on a railway track, where she was struck by a train and died. The concerns included weaknesses in recording risk assessments, observations and nurse allocation, limited staff awareness of current risk, and inadequate security of unit windows, which contributed to her absconding.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Staff lack of knowledge of current patient risk levels
Wider context from the report “(3) While I note that Risks Assessments were dynamic and said to be performed regularly there was no written record of them appearing on the RIO and staff appeared to have very little or no knowledge of the levels of risk at the instant in time .
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record risk assessments on RIO
Wider context from the report “(3) While I note that Risks Assessments were dynamic and said to be performed regularly there was no written record of them appearing on the RIO and staff appeared to have very little or no knowledge of the levels of risk at the instant in time.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a permanent record of nursing tasks performed
Wider context from the report “(4) The decision not to formally record levels of observations and nurse allocation to do them on the RIO record remains a cause for concern.
From the Evidence heard it is quite clear there can be no audit of a system which is not routinely recorded and some participants remain worryingly vague about the tasks they may/may not have performed .
This does not support the view that being in hospital means that a regular robust system of care and attention is given to patients who desperately need the help for which they have been admitted.
It is hoped that provision of a permanent record, would allow a culture of individual responsibility to flourish in the minds of all the nursing staff, so patients are looked after in the fullest sense of the word.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formally record observation levels
Wider context from the report “(4) The decision not to formally record levels of observations and nurse allocation to do them on the RIO record remains a cause for concern.
From the Evidence heard it is quite clear there can be no audit of a system which is not routinely recorded and some participants remain worryingly vague about the tasks they may/may not have performed.
This does not support the view that being in hospital means that a regular robust system of care and attention is given to patients who desperately need the help for which they have been admitted.
It is hoped that provision of a permanent record, would allow a culture of individual responsibility to flourish in the minds of all the nursing staff, so patients are looked after in the fullest sense of the word.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record nurse allocation for observations
Wider context from the report “(4) The decision not to formally record levels of observations and nurse allocation to do them on the RIO record remains a cause for concern.
From the Evidence heard it is quite clear there can be no audit of a system which is not routinely recorded and some participants remain worryingly vague about the tasks they may/may not have performed.
This does not support the view that being in hospital means that a regular robust system of care and attention is given to patients who desperately need the help for which they have been admitted.
It is hoped that provision of a permanent record, would allow a culture of individual responsibility to flourish in the minds of all the nursing staff, so patients are looked after in the fullest sense of the word.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Nebulous execution of the named nurse system
Wider context from the report “(1) The Evidence of Named Nurse system which was in operation at the time of Polly’s death indicated its execution to be somewhat nebulous.
I am encouraged by ████████ Evidence that the Trust has taken up the challenge and instituted new steps with 1:1 time and the placement of a ward board with names of nurses allocated to each patient so improving patient's access to them.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Retain Level 1 and 2 observation forms, allocation charts and shift planners for two years, uploading records when an observation incident occurs.
Verbatim wording from the response “• Level 1 and 2 (intermittent) observation forms (hard paper forms) are stored for two years, along with the allocation charts and the shift planners. They are only uploaded if an incident occurs during the period of observation. Therefore in the future should we need access to the observation chart records this will be able to be achieved. In the case of Polly, with the new policy in place the observation charts for the previous 24 hours would have been uploaded and all observation charts for the duration of her stay would have been stored.” Source location 2014-0469-Response-by-Devon-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue guidance on the information expected in completed observation documentation.
Verbatim wording from the response “• Revised documentation has been developed and is being implemented which includes room on the form for comments; there are guidelines on what we would expect to see written on these forms. From this the registered nurse on every shift would review the completed forms and provide an update on RiO in the progress notes. Again guidance will be issued as to what we would expect to see written.” Source location 2014-0469-Response-by-Devon-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement revised observation documentation with comment fields and a registered-nurse review and RiO progress-note update each shift.
Verbatim wording from the response “• Revised documentation has been developed and is being implemented which includes room on the form for comments; there are guidelines on what we would expect to see written on these forms. From this the registered nurse on every shift would review the completed forms and provide an update on RiO in the progress notes. Again guidance will be issued as to what we would expect to see written.” Source location 2014-0469-Response-by-Devon-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Storing intermittent observation forms for two years, with uploading only after incidents, is considered sufficient to enable future access when needed.
Verbatim wording from the response “• Level 1 and 2 (intermittent) observation forms (hard paper forms) are stored for two years, along with the allocation charts and the shift planners. They are only uploaded if an incident occurs during the period of observation. Therefore in the future should we need access to the observation chart records this will be able to be achieved. In the case of Polly, with the new policy in place the observation charts for the previous 24 hours would have been uploaded and all observation charts for the duration of her stay would have been stored.” Source location 2014-0469-Response-by-Devon-Partnership-NHS-Trust
Open published response
14 Jul 2014 Elaine JOBE · Prevention of Future Deaths report Exeter & Great Devon
View report summary
Concerns raised 5 Lack of records of observation levels and observing staff View source Lack of record keeping of risk assessments and assessor identities View source Failure to maintain records of staff training in risk assessments and observation procedures View source Failure to communicate patient status to incoming staff View source Failure to identify a named nurse responsible for each patient on every shift View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elaine JOBE · 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
Elaine JOBE, an informal voluntary psychiatric patient aged 53, was found hanging in a bathroom at Ocean View on 2 February 2011 after being placed on general hourly observation. Resuscitation and transfer to hospital did not avert her death. Concerns included inadequate records of risk assessments and observations, staff training, and communication of patient status and monitoring responsibilities between shifts.
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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of records of observation levels and observing staff
Wider context from the report “(1) Lack of record keeping
Inadequate/lack of record keeping on the Ri O of
(i) Risk Assessments and details of those persons making the assessments.
(ii) Lack of information regarding the Levels of Observations and the persons actually making the observations.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of record keeping of risk assessments and assessor identities
Wider context from the report “(1) Lack of record keeping
Inadequate/lack of record keeping on the Ri O of
(i) Risk Assessments and details of those persons making the assessments.
(ii) Lack of information regarding the Levels of Observations and the persons actually making the observations.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain records of staff training in risk assessments and observation procedures
Wider context from the report “(2)Training
Records of training of staff in the making of Risk Assessments and in understanding the meaning of the different Levels of Obs. and implementation of same.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate patient status to incoming staff
Wider context from the report “(3)Communication of patient status to incoming staff
Communication of patient status with other members of staff and identification of a named nurse with responsibility for each patient on every shift needs to be reviewed so all staff are clear as to which patients they must monitor.
” 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 Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify a named nurse responsible for each patient on every shift
Wider context from the report “(3)Communication of patient status to incoming staff
Communication of patient status with other members of staff and identification of a named nurse with responsibility for each patient on every shift needs to be reviewed so all staff are clear as to which patients they must monitor.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement electronic Rio recording of inpatient risk assessments, including automatic recording of assessment times and responsible staff.
Verbatim wording from the response “Since the sad death of Elaine the following changes to practice have been made and can be evidenced.” Source location 2014-0350-Response-by-Devon-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the inpatient Engagement and Safety Policy, then deliver local ward-based training and collect evidence of completion.
Verbatim wording from the response “3/ The policy is currently under review, once this is completed, (deadline 31st October 2014), local ward-based training will be delivered on the policy and evidence collected.” Source location 2014-0350-Response-by-Devon-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide feedback on risk assessments and risk-management plans, and review random monthly samples to demonstrate staff competency.
Verbatim wording from the response “2/ The Facilitator will provide feedback on risk assessments and formulating risk management plans based on the Standard Operating Procedures and best practice. Each month a random sample of risk assessments will be reviewed to demonstrate competency.” Source location 2014-0350-Response-by-Devon-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide recurring risk-management training for registered and unregistered staff, with ward-specific policy training and induction for new staff.
Verbatim wording from the response “Since the sad death of Elaine the trust has reviewed its arrangements and put in to place the following. The Trust requires registered and unregistered staff to be trained in Level 1 Risk Management and all registered staff to be trained to Level 2. Training is repeated every 3 years. Training reports show that all staff have completed Levels 1 and 2 dependent on their registration.” Source location 2014-0350-Response-by-Devon-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit shift planners randomly to verify completion of all required areas.
Verbatim wording from the response “7/ Random audit of the shift planners to be carried out to ensure completion of all areas.” Source location 2014-0350-Response-by-Devon-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update inpatient risk assessments weekly and document daily risk discussions in electronic patient records.
Verbatim wording from the response “Risk assessments are to be updated on the inpatient service weekly. Risk is discussed on a daily basis in the morning patient review meetings, during handovers and at ward rounds reviews are documented directly onto the electronic patient care record.” Source location 2014-0350-Response-by-Devon-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use ward allocation boards, shift planners, staff identification boards and minimum handover standards to communicate patient allocations and status to incoming staff.
Verbatim wording from the response “Since the death of Elaine the ward has an allocation board that is completed for every 24-hour period, showing the staff on duty and which patients they are allocated to. The board is in a prominent position on the ward so that staff and patients can see it. Next to this board is a staff photo board to help patients recognise staff members if they are new to the ward.” Source location 2014-0350-Response-by-Devon-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement policy-based recording and staff allocation for heightened observation levels, including electronic records and hourly allocation charts.
Verbatim wording from the response “(ii) The Trust Inpatient Service Engagement and Safety Policy sets clear expectations on the recording of observation levels, both in terms of directly onto the electronic care record for any patient on heightened levels of observation and for allocating staff to carry out the observations.” Source location 2014-0350-Response-by-Devon-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit monthly a random sample of patients on observation Levels 2–4 to verify recording in electronic records and staff allocation records.
Verbatim wording from the response “4/ Random monthly audits of patients on Levels 2-4 to ensure recording of observation levels are embedded as per the policy in both the electronic patient record and on the staff allocation record” Source location 2014-0350-Response-by-Devon-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing policies, standards and guidance address the concerns; new standards are not required, though further assurance actions will be implemented.
Verbatim wording from the response “The Trust has policies, standards and guidance in place for the areas of concern noted in the report. It is not seen as required to introduce new standards, but to ensure the embeddedness of those currently in place. The Trust has several assurance measures in place, but further actions as described below will be put in place to provide additional assurance.” Source location 2014-0350-Response-by-Devon-Partnership-NHS-Trust
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations