Recipient

Foxhayes Surgery GP Practice

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First report 25 Jun 2026•Latest report 25 Jun 2026

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Foxhayes Surgery GP Practice linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Devon, Plymouth and Torbay

    AI-generated summary

    David Joyce · 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 Joyce, who had a history of mental health difficulties, died by suicide at his home on 31 August 2023 after being found having suspended himself. The concerns included a lack of follow-up and consideration of mental health referral after he first sought help, prescribing Quetiapine without specialist input despite his reported symptoms and overdose, and a delay of 15 weeks before a medication review led to a change in treatment.

    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 Foxhayes Surgery GP Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to seek specialist guidance on medication appropriateness in complex mental health presentations

    Wider context from the report

    “2. David presented to the GP surgery again on 26th June. He reported that he’d had a ‘severe mental breakdown due to ongoing psychosis’ which had resulted in him taking an overdose and being arrested for being in possession of a weapon, and he’d been advised by Police mental health services to contact his GP for support. When he spoke to the GP, David informed her that he considered his most significant issue currently was depression, and said that he had not taken Quetiapine since he moved to Exeter some years previously. Despite the fact that David indicated depression to be his overriding concern, he had taken an overdose which resulted in hospital attendance, and he’d not taken Quetiapine for some time (and seemingly for different symptoms), the GP prescribed Quetiapine, without seeking guidance or input from a psychiatrist or mental health professional about whether that was an appropriate medication in the circumstances. No routine follow up appears to have taken place following that consultation. The next communication does not occur until the GP is informed that there had been a further suicide attempt resulting in a Mental Health Act Assessment of David on 22nd August. ”
    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 Foxhayes Surgery GP Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide routine follow-up after mental health consultation

    Wider context from the report

    “2. David presented to the GP surgery again on 26th June. He reported that he’d had a ‘severe mental breakdown due to ongoing psychosis’ which had resulted in him taking an overdose and being arrested for being in possession of a weapon, and he’d been advised by Police mental health services to contact his GP for support. When he spoke to the GP, David informed her that he considered his most significant issue currently was depression, and said that he had not taken Quetiapine since he moved to Exeter some years previously. Despite the fact that David indicated depression to be his overriding concern, he had taken an overdose which resulted in hospital attendance, and he’d not taken Quetiapine for some time (and seemingly for different symptoms), the GP prescribed Quetiapine, without seeking guidance or input from a psychiatrist or mental health professional about whether that was an appropriate medication in the circumstances. No routine follow up appears to have taken place following that consultation. The next communication does not occur until the GP is informed that there had been a further suicide attempt resulting in a Mental Health Act Assessment of David on 22nd August. ”
    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 Foxhayes Surgery GP Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in amending medication when presenting symptoms indicate a different treatment

    Wider context from the report

    “3. On 31st August 2023, when a medication review was conducted, it was established that David needed a different medication given his presenting symptoms. This medication amendment therefore did not take place until 15 weeks after David had initially sought help from the GP. ”
    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 Foxhayes Surgery GP Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to initiate follow-up after presentation with deteriorating mental health

    Wider context from the report

    “1. David first presented to the GP surgery on 16th May 2023, reporting a deterioration in his mental health. No follow up was initiated by the surgery despite David’s recorded past medical history of dissociated disorder, self-harm and suicide. There was no evidence that, on that occasion, there had been any consideration of referral to secondary or tertiary mental health services which may have been available to assist David and inform his 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 Foxhayes Surgery GP Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consider referral to secondary or tertiary mental health services

    Wider context from the report

    “1. David first presented to the GP surgery on 16th May 2023, reporting a deterioration in his mental health. No follow up was initiated by the surgery despite David’s recorded past medical history of dissociated disorder, self-harm and suicide. There was no evidence that, on that occasion, there had been any consideration of referral to secondary or tertiary mental health services which may have been available to assist David and inform his care; ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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

Data last updated 7 September 2026