Recipient

Knowle House Surgery

First report 2 Feb 2016•Latest report 2 Feb 2016

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 4
Stated actions: 3

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.

100%published responses found

3stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

2 Feb2016
Plymouth, Torbay and South Devon
Concerns raised4
1. Failure to re-refer patients to the Mental Health Team when clinically appropriate
2. Lack of a defined response process for rejected mental health assessment applications
3. Failure to promptly identify and bring rejected mental health assessment requests to clinical attention
1. Failure to review decisions not to re-refer patients to the Mental Health Team
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Meet with secondary-care psychiatry colleagues to discuss referral rejection and complete a Significant Event analysis of the death.
  Stated completed
2. Action
  Write jointly to the head of DRSS to request review of procedures for communicating rejected urgent mental-health referrals to requesting GPs.
  Stated planned
3. Action
  Establish robust procedures for safely reviewing post and electronic communications, supported by post audits and re-audit.
  Stated completed
Respondent positions 2
1. Position
  The hunger strike was considered likely to result in a slow suicide, so the urgent referral was not considered to require an immediate response.
  Disputes the concern
1. Position
  Existing procedures for reviewing post and electronic communication were considered robust enough to keep patients safe.
  Existing arrangements considered sufficient
AI-generated summary

Michael John Valentine · 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

Michael John Valentine was found deceased on 16 September 2015 after a period in which he disclosed that he was not eating and stated that he had been on hunger strike. The concerns included an urgent mental health assessment referral being rejected without being brought to the relevant clinician’s attention, the failure to make a second referral after he reported not eating for 25 days, and the absence of discussion of these issues in the surgery’s significant events meeting.

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 Knowle House Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to re-refer patients to the Mental Health Team when clinically appropriate
Wider context from the report
“(1) A fax rejecting the request for a mental health assessment was sent back to the Surgery. This was classed as routine and was not brought to the attention of ████████. It was left in a tray for dealing (filing) but, unfortunately, due to staff absence, this did not come to light until after the death of Mr Valentine. (2) After the telephone consultation on 10 September, ████████ agreed that it would have been appropriate to refer Mr Valentine to the Mental Health Team for a second time given his disclosure that he had not eaten for 25 days. (3) ████████ told the Court that there had been a significant events meeting which had looked at the administrative shortcomings in the Surgery. There had been no discussion, however, of her decision not to re-refer following the 10 September telephone contact. Similarly, there has been no discussion of what to do where an application for a mental health assessment has been rejected. ”
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 Knowle House Surgery; that does not assign responsibility.
PFD Monitor interpretation
Lack of a defined response process for rejected mental health assessment applications
Wider context from the report
“(1) A fax rejecting the request for a mental health assessment was sent back to the Surgery. This was classed as routine and was not brought to the attention of ████████. It was left in a tray for dealing (filing) but, unfortunately, due to staff absence, this did not come to light until after the death of Mr Valentine. (2) After the telephone consultation on 10 September, ████████ agreed that it would have been appropriate to refer Mr Valentine to the Mental Health Team for a second time given his disclosure that he had not eaten for 25 days. (3) ████████ told the Court that there had been a significant events meeting which had looked at the administrative shortcomings in the Surgery. There had been no discussion, however, of her decision not to re-refer following the 10 September telephone contact. Similarly, there has been no discussion of what to do where an application for a mental health assessment has been rejected. ”
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 Knowle House Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to promptly identify and bring rejected mental health assessment requests to clinical attention
Wider context from the report
“(1) A fax rejecting the request for a mental health assessment was sent back to the Surgery. This was classed as routine and was not brought to the attention of ████████. It was left in a tray for dealing (filing) but, unfortunately, due to staff absence, this did not come to light until after the death of Mr Valentine. (2) After the telephone consultation on 10 September, ████████ agreed that it would have been appropriate to refer Mr Valentine to the Mental Health Team for a second time given his disclosure that he had not eaten for 25 days. (3) ████████ told the Court that there had been a significant events meeting which had looked at the administrative shortcomings in the Surgery. There had been no discussion, however, of her decision not to re-refer following the 10 September telephone contact. Similarly, there has been no discussion of what to do where an application for a mental health assessment has been rejected. ”
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 Knowle House Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to review decisions not to re-refer patients to the Mental Health Team
Wider context from the report
“(1) A fax rejecting the request for a mental health assessment was sent back to the Surgery. This was classed as routine and was not brought to the attention of ████████. It was left in a tray for dealing (filing) but, unfortunately, due to staff absence, this did not come to light until after the death of Mr Valentine. (2) After the telephone consultation on 10 September, ████████ agreed that it would have been appropriate to refer Mr Valentine to the Mental Health Team for a second time given his disclosure that he had not eaten for 25 days. (3) ████████ told the Court that there had been a significant events meeting which had looked at the administrative shortcomings in the Surgery. There had been no discussion, however, of her decision not to re-refer following the 10 September telephone contact. Similarly, there has been no discussion of what to do where an application for a mental health assessment has been rejected. ”
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
Meet with secondary-care psychiatry colleagues to discuss referral rejection and complete a Significant Event analysis of the death.

Verbatim wording from the response
“We met with our Secondary Care Psychiatry colleagues on 18th March 2016 and discussed the rejection process as well as carrying out a Significant Event analysis on Mr Valentine’s death.”

Source location
Michael-Valentine-Response
Page 1 · response
Published 2 February 2016
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
Write jointly to the head of DRSS to request review of procedures for communicating rejected urgent mental-health referrals to requesting GPs.

Verbatim wording from the response
“It was discussed between the parties that any urgent referrals rejected should be phoned through to the surgery and this should be confirmed by DRSS as Mental Health Services triage referrals on their behalf.”

Source location
Michael-Valentine-Response
Page 2 · response
Published 2 February 2016
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 robust procedures for safely reviewing post and electronic communications, supported by post audits and re-audit.

Verbatim wording from the response
“An audit of post was taken on 23/2/16. 235 pieces of correspondence were referred on this day. 216 were distributed to the GPs working that day. 1 GP does not routinely work that day and 19 pieces of correspondence were reviewed by the Duty Doctor for urgency and 18 pieces of correspondence were deemed safe to leave for the doctors return one day later.”

Source location
Michael-Valentine-Response
Page 1 · response
Published 2 February 2016
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
The hunger strike was considered likely to result in a slow suicide, so the urgent referral was not considered to require an immediate response.

Verbatim wording from the response
“After discussion it was confirmed that the referral requested was a Mental Capacity Assessment and not a Mental Health Act Assessment. Although the referral was put through as urgent the fact that he was on hunger strike meant that his suicide was likely to be slow and the request for a physical health examination was reasonable.”

Source location
Michael-Valentine-Response
Page 2 · response
Published 2 February 2016
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 procedures for reviewing post and electronic communication were considered robust enough to keep patients safe.

Verbatim wording from the response
“On balance we are happy that we now have robust procedures for reviewing post and electronic communication within the Practice to keep our patients safe.”

Source location
Michael-Valentine-Response
Page 1 · response
Published 2 February 2016
Open published response

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised4

Failure to re-refer patients to the Mental Health Team when clinically appropriate

Lack of a defined response process for rejected mental health assessment applications

Failure to promptly identify and bring rejected mental health assessment requests to clinical attention

Failure to review decisions not to re-refer patients to the Mental Health Team

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 3

Respondent positions 2