Langdon Hospital

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First report 2 Dec 2023•Latest report 2 Dec 2023

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
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. Plymouth, Torbay and South Devon

    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 Langdon Hospital; 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 Langdon Hospital; 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 Langdon Hospital; 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 Langdon Hospital; 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 Langdon Hospital; 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 Langdon Hospital; 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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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