Knowle House SurgeryIncludes reports addressed to a minister or senior office-holder acting for this organisation.

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First report 2 Feb 2016•Latest report 2 Feb 2016

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
4

Across all linked responses

Stated actions
3

Described in responses

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.

  1. Addressed to: Senior Partner, Knowle House Surgery.

    Plymouth, Torbay and South Devon

    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
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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