23 Mar 2020 Lewis Charles Francis · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 2 Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum View source Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment View source
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
Lewis Charles Francis · 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
Lewis Charles Francis was arrested after stabbing his mother while acutely psychotic and was remanded to HM Prison Exeter after no ready medium secure mental health hospital transfer facility was available. He died at the prison on 24 April 2017 by suicide as a result of suspension by a ligature. Concerns included the lack of a ready transfer mechanism from police custody to medium secure mental health facilities, and insufficient understanding of the needs and vulnerabilities of prisoners on the autistic spectrum.
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 Livewell Southwest; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum
Wider context from the report “(2) Evidence at the inquest suggested that there was an insufficient understanding of the special needs and vulnerabilities of those prisoners who are within the autistic spectrum
” 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 Livewell Southwest; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment
Wider context from the report “(1) At present there is no mechanism for the ready transfer of a person in police custody within the police areas of Devon and Cornwall, Avon and Somerset, Wiltshire and Gloucestershire from police custody to a medium secure mental health facility for assessment / treatment under sections 2 and 3 of the Mental Health Act 1983 where such a person is suspected of or charged with a serious crime. Such an arrangement exists in the West Midlands where a Memorandum of Understanding has been developed and agreed between relevant agencies.
” Open source report
Concerns raised 2 Unclear mental health care pathways for professionals after discharge View source Lack of triage of GP appointment requests for likely clinical difficulty View source
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
Graeme Robert Mathieson · 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
Graeme Robert Mathieson died following an intentional overdose of prescribed medication. The inquest concluded suicide and identified gross failures to provide basic medical attention while he was in a dependent position, which caused or contributed to the outcome. Concerns included time constraints affecting recognition of his serious psychiatric condition, confusion about mental-health care pathways, and weaknesses in transfer processes.
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 Livewell Southwest; that does not assign responsibility.
PFD Monitor interpretation Unclear mental health care pathways for professionals after discharge
Wider context from the report “It became apparent during the course of the inquest that a number of professionals (both GPs and care coordinators) were confused or unclear about the correct pathway for ████████ to follow once he had been wrongly discharged from the local CM HT . I indicated that I felt it may be beneficial for Livewell Southwest to add a ‘Professionals’ tab or page to its website so that doctors and other professionals could refer to it in the event of uncertainty. I suggested that it may be sensible for a doctor representing GPs locally to sit down with an individual from Livewell Southwest to ensure that any areas of ongoing confusion were recognised and appropriately addressed.
” 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 Livewell Southwest; that does not assign responsibility.
PFD Monitor interpretation Lack of triage of GP appointment requests for likely clinical difficulty
Wider context from the report “At page 20 of my judgement I found that at the appointment on 10 August 2016 the time constraints under which ████████ was obliged to work meant that he was faced with trying to achieve the impossible. I said that I was sure that the very real constraints of time had had a direct impact on the outcome of the appointment. I said that it would have been better if the likely difficulties in this regard had been recognised at the point that Mr Matheson or his sister had asked to have an appointment . If there had been some sort of triage system in place , as I understand to be the case in other practices, this could have been recognised from the outset.
I am aware that while some GP practices operate triage system there are plenty of others that do not . I think it may be beneficial for the facts of this case to be shared with all GPs in the area as a learning exercise. What I want to ensure, as far as possible, is that another GP is not placed in the same situation as ████████ on 10 August 2016 with the nearly inevitable conclusion that a patient’s serious psychiatric condition is not recognised .
” Open source report
Concerns raised 3 Shortage of care coordinators View source Failure to involve and inform families in psychiatric care View source Failure of risk assessments to address periodic impulsivity View source
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
Martin Glyn Baker · 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
Martin Glyn Baker, who had longstanding mental health difficulties and a history of suicide attempts, died following a prescription drug-related death. The inquest identified concerns about inadequate communication with his family, a shortage of care coordinators, and a risk assessment that did not address his periodic impulsivity.
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 Livewell Southwest; that does not assign responsibility.
PFD Monitor interpretation Shortage of care coordinators
Wider context from the report “(2) It was also accepted in evidence that at the time of these events there was a shortage of care coordinators something described as “very far from ideal.” I was advised that this situation has now been corrected. Nevertheless, it was the clear view of the family, which I accepted, that in the absence both of a care coordinator and the involvement of the family there had been no one to act as an advocate on Mr Baker’s behalf , something that had been to his detriment.
” 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 Livewell Southwest; that does not assign responsibility.
PFD Monitor interpretation Failure to involve and inform families in psychiatric care
Wider context from the report “(1) It was accepted in evidence that there had been a lack of communication with the family . They had not been involved in any psychiatric reviews instead, on one occassion, a consultant was left to rely upon information provided by a junior healthcare assistant. At inquest I expressed my view that where a patient has signed a consent form authorising discussion of relevant events with the family, the default position should be that there will be involvement of the family in the absence of any good reason not to do so, for example, a patient’s subsequent express instruction not to share something with the family. In this case the family were unaware that Mr Baker had been discharged from psychiatric support and were unaware of what to do in the event of deterioration in Mr Baker’s condition .
” 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 Livewell Southwest; that does not assign responsibility.
PFD Monitor interpretation Failure of risk assessments to address periodic impulsivity
Wider context from the report “(3) It was accepted in evidence by ████████ that his risk assessment failed to address periodic impulsivity that Mr Baker demonstrated . I found this was not causative of the death. Nevertheless, I felt there was a point of learning that may well have a bearing in the care of future patients and I felt it appropriate to bring it to your attention.
” Open source report
Concerns raised 4 Failure to re-refer patients to the Mental Health Team when clinically appropriate View source Lack of a defined response process for rejected mental health assessment applications View source Failure to promptly identify and bring rejected mental health assessment requests to clinical attention View source Failure to review decisions not to re-refer patients to the Mental Health Team View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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 Livewell Southwest; 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 Livewell Southwest; 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 Livewell Southwest; 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 Livewell Southwest; 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 Review the process for urgent referrals.
Verbatim wording from the response “I am writing in response to your letter sent to our Medical Director. In order to progress this we have had a meeting with Senior Management of Livewell South West and myself as Clinical Director of Adult Mental Health and have reviewed the case. We have reviewed the process of urgent referrals. We note that Knowle House Surgery considered this as part of their Significant Event Process and we met with the practice on Friday 18th March. We understand that the practice will forward a record of the meeting to you.” Source location Michael-Valentine-Response2
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 Contact referrers directly to confirm assessment outcomes whenever staff reject urgent referrals.
Verbatim wording from the response “1. In future any staff that reject an urgent referral will be contacting the referrer direct to confirm the outcome of their assessment of the referral.” Source location Michael-Valentine-Response2
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations