Recipient

Langdon Hospital

First report 2 Dec 2023•Latest report 2 Dec 2023

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: 0%
Concerns addressed: 0
Stated actions: 0

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

2 Dec2023
Plymouth, Torbay and South Devon
Concerns raised6
1. Lack of clarity over the timing of observation chart checks
2. Lack of clarity over responsibility for feedback on observation chart problems
3. Failure to ensure staff awareness of relevant suicide risk history
1. Lack of clarity over responsibility for checking observation charts
2. Failure to include historical and contextual risks in risk analysis
3. Failure to complete observation charts adequately
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

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

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 raised6

Lack of clarity over the timing of observation chart checks

Lack of clarity over responsibility for feedback on observation chart problems

Failure to ensure staff awareness of relevant suicide risk history

Lack of clarity over responsibility for checking observation charts

Failure to include historical and contextual risks in risk analysis

Failure to complete observation charts adequately