Concerns raised 1 Lack of out-of-hours consultant radiologist cover for hospitals in Exeter, Plymouth and Torbay 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
John Thomas Cleave · 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
John Thomas Cleave sustained a cervical spine fracture and probable haemothorax in an unwitnessed fall at his allotment on 28 December 2023. He died at Torbay Hospital on 29 December 2023 after vomiting, aspirating and suffering cardiac arrest. Concerns included the CT scan report failing to identify a high suspicion of haemothorax, the lack of out-of-hours consultant radiologist cover, and his care not being transferred promptly to a major trauma centre.
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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of out-of-hours consultant radiologist cover for hospitals in Exeter, Plymouth and Torbay
Wider context from the report “During the course of the inquest, evidence was given to me that a level of complexity due to the Deceased’s medical history, his injuries and an apparent artifact in the CT-Scan caused by metalwork in the Deceased’s spine from previous surgery required the expertise of a consultant radiologist. I was informed that there was (and is still) no out of hours consultant radiologist cover for hospitals in Exeter, Plymouth and Torbay .
I am concerned that there will be from time to time a need for scans and x-rays to be considered and interpreted at consultant radiologist level to facilitate urgent treatment and there is at present a gap in such cover which puts patients at risk .
” Open source report
Concerns raised 2 Failure of the Special Allocation Scheme to meet the needs of autistic patients View source Lack of appropriate care and support for autistic people in crisis without a treatable mental health condition View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Benjamin Robert Compton · 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
Benjamin Robert Compton, who had autism, experienced a deterioration in his physical and mental wellbeing and escalating distress. In the early hours of 1 February 2022, he left his supported accommodation and was hit by a lorry on the M5. The substantive concerns included gaps in support for autistic people in crisis and the inability of the Special Allocation Scheme to meet Benjamin’s needs.
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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of the Special Allocation Scheme to meet the needs of autistic patients
Wider context from the report “(2) Benjamin was removed from his GP practice due to violent behaviour and allocated to the Special Allocation Scheme. This scheme was not able to meet the needs of a patient such as Benjamin with a diagnosis of Autism Spectrum disorder .
” 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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate care and support for autistic people in crisis without a treatable mental health condition
Wider context from the report “(1) The evidence reveals that there was a gap in the provision of care for individuals suffering with autism and in crisis, that remains the case today both in Devon and nationally . Evidence was heard that a gap exists with autistic people in distress and or dysregulation with no treatable mental health condition and there is a grey area around treatment. This is beyond the skills of social care providers . And unless the individual meets the criteria for treatment under the Mental Health Act there is very little support .
” 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 Integrate outreach and inreach provision into the care pathway to prevent unnecessary admissions and support timely care.
Verbatim wording from the response “Alongside this, an outreach and inreach service will be integrated into the pathway to prevent unnecessary admissions and ensure timely, appropriate care.” Source location Response from NHS Devon
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 Implement Oliver McGowan mandatory training to strengthen community skills and reasonable adjustments across services.
Verbatim wording from the response “Furthermore, the implementation of the Oliver McGowan mandatory training will enhance community skills and promote reasonable adjustments across services, ensuring that autistic individuals in crisis receive appropriate support.” Source location Response from NHS Devon
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 Conduct a comprehensive community delivery review covering primary, secondary, social-care and acute services to improve crisis-support pathways.
Verbatim wording from the response “To review and improve current processes for crisis support, the Learning Disability and Neurodiversity commissioning team will conduct a comprehensive community delivery review in 2025/2026. This review will cover primary care, secondary care, social care, and acute services to optimise care pathways for this population.” Source location Response from NHS Devon
Open published response
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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 Strengthen Special Allocation Scheme processes by checking practice compliance and adding clear appeal-panel agenda items to verify appropriate allocation procedures.
Verbatim wording from the response “Response:
We have previously made improvements to processes and requirements in this scheme since this case. The changes include reviewing the process the practice has followed to ensure it meets all the requirements for allocation to the Special Allocation Scheme and where an appeal is made, the panel agenda has clear items to check/ensure the practice has followed the appropriate processes for assigning to the scheme.” Source location Response from NHS Devon
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 Raise awareness and implement reasonable adjustments to improve mental-health support for autistic people.
Verbatim wording from the response “Response:
Devon ICB recognises the existing commissioning gap for individuals with autism who experience crisis. In response, significant work has been undertaken in 2023–2024 to” Source location Response from NHS Devon
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 Modify Special Allocation Scheme procedures to require practices to confirm consideration of alternative approaches before placement.
Verbatim wording from the response “Following receiving this Prevention of Future Deaths notice we have additionally considered what extra action can be taken to additionally strengthen arrangements. We have determined to make a modification to the Special Allocation Scheme Standard Operating Procedures (SOP) that specifically requires written confirmation from Practices that they considered all possible alternative approaches to providing primary medical services prior to making the placement. This change was enacted in May 2025.” Source location Response from NHS Devon
Open published response
Concerns raised 4 Failure to achieve clear communication of key information within community mental health teams View source Failure to routinely detect Clozapine-associated cardiomyopathies View source Limited provision of Clozapine side-effect and red-flag information to patients attending GP practices View source Failure to achieve clear communication of key information with other agencies involved in patient care 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
William Antony Northcott · 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
William Antony Northcott, who had treatment-resistant schizophrenia, was found deceased on 13 July 2021 after suffering a sudden fatal cardiac arrhythmia. The report raised concerns about the adequacy and consistency of information on clozapine side effects and cardiac warning signs, the detection of cardiomyopathies in patients taking clozapine, and communication between agencies and care teams.
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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to achieve clear communication of key information within community mental health teams
Wider context from the report “It is clear that patients suffering with treatment resistant schizophrenia are complex, and as such there are often a number of different agencies involved in an individual's care. In addition, there are often multiple members of the same team involved in an individual's care. During the inquest it became clear that, at times, communication of important issues was not as clear as it should have been . I note that Devon Partnership NHS Trust has significant training available for its staff and other agencies it engages with in relation to patients who are prescribed Clozapine. However, it would be of great assistance to understand what Devon Partnership NHS Trust is doing to ensure that optimum communication of key information is achieved within the community mental health team , and when dealing with its other agencies involved in a patient's care.
” 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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely detect Clozapine-associated cardiomyopathies
Wider context from the report “The risk of myocarditis is reasonably well explained in Devon Partnership NHS Trust's policy documentation, but there is less of a focus on cardiomyopathies which would include left ventricular hypertrophy . I understand that the Trust's guidance is based on national guidance. Annual ECGs are required for patients prescribed Clozapine and questions about cardiac function will now be asked at monthly Clozapine clinics. However, I understand that ECGs are not a diagnostic tool used to assist in the diagnosis of cardiomyopathies such as left ventricular hypertrophy and that left ventricular hypertrophy can be asymptomatic. I also understand that an echocardiogram may be able to identify such cardiomyopathies, but that this is not currently required on initiation of Clozapine or routinely at any other time whilst a patient is taking Clozapine .
I am concerned that these cardiomyopathies could therefore go undetected in patients prescribed Clozapine and leave them at unknown increased risk of fatal cardiac arrhythmias, as occurred in William's case. Given that the Trust's guidance is based on national guidance I am concerned this may be a national issue.
” 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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Limited provision of Clozapine side-effect and red-flag information to patients attending GP practices
Wider context from the report “Currently around 60% of the cohort of patients prescribed Clozapine who are under the care of Devon Partnership Trust have access to these clinics. The other 40% will attend their GP surgery for their monthly Clozapine phlebotomy service. The phlebotomy service provided at a GP practice is usually an appointment with a non-qualified member of staff, who will not have been specifically trained in the side effects of Clozapine. I am therefore concerned that the level of care provided to patients attending Clozapine clinics on a monthly basis, is likely to be superior to the care provided to those patients who attend their GP practice. In particular, I am concerned that any discussion and repetition of information surrounding red flags and side effects associated with Clozapine, and advice about when to seek medical attention, will be significantly more limited for those patients attending their GP practice than for those attending the monthly Clozapine clinics. I am also concerned that this limitation is likely to extend further than the 40% of patients in receipt of Clozapine under the care of Devon Partnership NHS Trust and that this may be a national issue.
” 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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to achieve clear communication of key information with other agencies involved in patient care
Wider context from the report “It is clear that patients suffering with treatment resistant schizophrenia are complex, and as such there are often a number of different agencies involved in an individual's care. In addition, there are often multiple members of the same team involved in an individual's care. During the inquest it became clear that, at times, communication of important issues was not as clear as it should have been . I note that Devon Partnership NHS Trust has significant training available for its staff and other agencies it engages with in relation to patients who are prescribed Clozapine. However, it would be of great assistance to understand what Devon Partnership NHS Trust is doing to ensure that optimum communication of key information is achieved within the community mental health team, and when dealing with its other agencies involved in a patient's care.
” 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 Cascade additional funding to support more Clozapine clinics and increase access to specially trained professionals.
Verbatim wording from the response “Response:
In the 2025/26 financial year, NHS Devon will be cascading additional funding to Devon Partnership NHS Trust to support the implementation of more Clozapine clinics. This will increase capacity and allow more patients to receive their care from specially trained professionals. The clinics provide vital opportunities to reinforce education around Clozapine side effects and risks, including red flags and when to seek urgent medical attention. We believe this will reduce variability in patient care and improve overall safety for individuals receiving Clozapine.” Source location Response from Devon ICB
Open published response
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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 Implement relevant changes arising from national policy developments within local systems.
Verbatim wording from the response “Response:
NHS Devon is aware that clinical leads from Devon Partnership NHS Trust are in active discussions with the Royal College of Psychiatrists to consider new and emerging national evidence, including the findings set out in The Williams Protocol. NHS Devon will ensure that the outcomes of these discussions, and any changes to national policy, are shared and implemented within local systems.” Source location Response from Devon ICB
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 Share discussion outcomes and relevant national policy changes concerning Clozapine cardiac monitoring within local systems.
Verbatim wording from the response “Response:
NHS Devon is aware that clinical leads from Devon Partnership NHS Trust are in active discussions with the Royal College of Psychiatrists to consider new and emerging national evidence, including the findings set out in The Williams Protocol. NHS Devon will ensure that the outcomes of these discussions, and any changes to national policy, are shared and implemented within local systems.” Source location Response from Devon ICB
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 Cardiac monitoring changes depend on updates to national clinical guidance, with local implementation following any such changes.
Verbatim wording from the response “Response:
NHS Devon is aware that clinical leads from Devon Partnership NHS Trust are in active discussions with the Royal College of Psychiatrists to consider new and emerging national evidence, including the findings set out in The Williams Protocol. NHS Devon will ensure that the outcomes of these discussions, and any changes to national policy, are shared and implemented within local systems.” Source location Response from Devon ICB
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 Devon Partnership NHS Trust is responsible for improving internal and cross-agency communication, so no direct response is provided.
Verbatim wording from the response “Concern 3:
Patients with treatment-resistant schizophrenia typically receive support from multiple teams and agencies. During the inquest, it became apparent that communication between professionals was, at times, suboptimal. The Coroner seeks assurance that Devon Partnership NHS Trust is working to improve internal and cross-agency communication.” Source location Response from Devon ICB
Open published response
Concerns raised 1 Failure to provide timely care and 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
Name not published · 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
The deceased suffered from debilitating conditions and lived in insanitary conditions. After a long lie and a subsequent visit where she was found in extremis with sepsis, she died at Torbay Hospital on 25 February 2022; the report identified a probable missed opportunity to provide timely care and treatment before she was found in extremis.
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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely care and treatment
Wider context from the report “(1) On the balance of probability there was a missed opportunity to afford timely care and treatment to the deceased before she was found in extremis on the 24th of February 2022.
” Open source report
Concerns raised 1 Failure to prevent persons from accessing multiple prescriptions across different GP surgeries 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
David Lee Gomer TRAVERS · 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
Mr Travers was found unresponsive and declared deceased on 27 October 2017 after taking illicit and prescription drugs and alcohol, including heroin. The principal concern was that people could access multiple prescriptions from different GP surgeries, with prescription drugs potentially being used to obtain illicit drugs or entering the illegal drugs market.
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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent persons from accessing multiple prescriptions across different GP surgeries
Wider context from the report “Evidence from several witnesses indicated that Mr Travers was able to access multiple prescriptions for drugs by moving around Plymouth and the surrounding area and presenting to different GP surgeries as requiring drugs.
Evidence also indicated that Mr Travers would sell or barter prescription drugs to obtain illicit drugs.
There are apparently measures in place to raise alerts across GP surgeries and NHS Trusts to exchange information about persons who may be attempting to exploit the issuing of drug prescriptions, however given the above evidence, I am concerned that it is nevertheless still too easy for persons to access multiple prescriptions . This presents a risk to those who are able to obtain and take excessive amounts of prescription drugs and a route by which prescription drugs can enter an illegal drugs market
” Open source report
Concerns raised 2 Lack of an appropriate care pathway for people with learning difficulties and associated medical problems View source Failure of mainstream adult support services to provide care for people with intellectual disabilities View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jessica Mary BIRKHEAD · 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
Jessica Mary Birkhead was found unconscious by her husband on 28 July 2015 and died in hospital later that day after ingesting a large quantity of paracetamol and pregabalin, which was not prescribed for her. The concerns raised were that mainstream adult support services were not equipped to meet her intellectual disabilities and that appropriate support pathways should be considered for people with similar learning difficulties and associated medical problems.
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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of an appropriate care pathway for people with learning difficulties and associated medical problems
Wider context from the report “1. Although Jessica had been referred to a Consultant Psychiatrist in learning disability, the other support services offered to Jessica were main stream adult services, Jessica’s mother, a GP, is of the view that they were not equipped to deal with someone of Jessica’s intellectual disabilities.
2. Perhaps Jessica’s case could be looked at to consider the appropriate pathway for others in the future in a similar situation to Jessica to give appropriate support and care at a level appropriate taking into account any learning difficulties and associated medical problems .
” 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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of mainstream adult support services to provide care for people with intellectual disabilities
Wider context from the report “1. Although Jessica had been referred to a Consultant Psychiatrist in learning disability, the other support services offered to Jessica were main stream adult services , Jessica’s mother, a GP, is of the view that they were not equipped to deal with someone of Jessica’s intellectual disabilities .
2. Perhaps Jessica’s case could be looked at to consider the appropriate pathway for others in the future in a similar situation to Jessica to give appropriate support and care at a level appropriate taking into account any learning difficulties and associated medical problems.
” 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 Provide acute-care liaison nurses in all large Devon general hospitals, supplemented by additional learning-disability liaison nurses.
Verbatim wording from the response “In secondary care there is an Acute Care Liaison nurse in all of the large general hospitals in Devon and additional liaison learning disability nurses offering support. The specification for this service is explicit stating it is there ‘to provide a link between social care/community learning disability services/primary care and facilitate health promotion supporting people to access other health services i.e. chiropody, dentistry, mental health services district nurses etc.’ In addition the specification states that this service will “support good mental health outcomes and access to all universal mental health services”.” Source location 2016-0208-Response-by-Northern-Eastern-and-Western-Devon-Clinical-Commissioning-Group
Open published response
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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 Assess with provider organisations whether the 1Green Light audit tool can be applied to community services and agree its appropriate deployment.
Verbatim wording from the response “The “1Green Light” audit tool (NDTi, 2013) has previously been deployed to review and benchmark inpatient services response to people who have mental health needs and also a learning disability and/or autism. The CCG clinical and quality leads will assess with the leads of relevant provider organisations whether this tool could appropriately be applied to other community services to provide a review of access of mental health services to individuals and to identify what further reasonable adjustments are needed in services to enable service improvement. Assessment and agreement as to how this tool can be appropriately deployed will be completed in 2016/17 in order to inform any quality improvement initiatives to be undertaken in 2017/18.” Source location 2016-0208-Response-by-Northern-Eastern-and-Western-Devon-Clinical-Commissioning-Group
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 Provide approximately 20 primary-care learning-disability nurses across Devon to support access to primary-care services.
Verbatim wording from the response “In primary care there are approximately 20 nurses operating across Devon to ensure that individuals have good support in primary care services. This is a significantly higher level of service than other CCG’s. The Extended Service provision of Annual Health Checks in Primary Care for people with learning disabilities has been maintained. In addition work has taken place with the locality screening teams (Cervical cancer, Bowel Cancer, Abdominal Aortic Aneurysm, Breast cancer and Diabetic Retinopathy) and immunisation teams (influenza) to increase uptake of these services by people with learning disabilities.” Source location 2016-0208-Response-by-Northern-Eastern-and-Western-Devon-Clinical-Commissioning-Group
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 Commission learning-disability support services to improve access to mainstream healthcare.
Verbatim wording from the response “The CCG has specifically commissioned services with Devon Partnership NHS Trust (DPT) to support the access of people who have a learning disability to mainstream services.” Source location 2016-0208-Response-by-Northern-Eastern-and-Western-Devon-Clinical-Commissioning-Group
Open published response
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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 Parallel healthcare services for people with learning disabilities are not practical or clinically desirable; access should remain through mainstream services with reasonable adjustments.
Verbatim wording from the response “In terms of context, the CCG’s approach to commissioning access to mainstream healthcare services for people with a learning disability is in accordance with national policy. People who have a learning disability should have access to the same specialists as the general population, whilst recognising that reasonable adjustments may need to be made in services to enable this access. It is not practical or indeed clinically desirable to run a host of parallel health services for people who have a learning disability as they should always be able to access the expert input they need as patients, for example in primary care, physical acute medical and surgical services or mental health services.” Source location 2016-0208-Response-by-Northern-Eastern-and-Western-Devon-Clinical-Commissioning-Group
Open published response
Concerns raised 4 Lack of available psychiatric inpatient beds View source Failure to correctly apply the Mental Health Act in physical care environments View source Delays in discharge caused by inadequate social and community care resources View source Lack of adequate mental health training for physical healthcare staff 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
Wendy Louise Telfer · 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
Wendy Louise Telfer died on 20 March 2016 in hospital from an overdose of purchased non-prescribed medication taken five days earlier; the medical cause of death was recorded as liver failure due to paracetamol overdose, with asthma also recorded. The report identified concerns about missed opportunities to keep Wendy safe, confusion about applying the Mental Health Act in a physical care setting, and the lack of an available psychiatric inpatient bed.
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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of available psychiatric inpatient beds
Wider context from the report “(2) Wendy was to be admitted to a psychiatric bed at one stage of this final hospital stay, but she could not be transferred immediately due to the lack of beds . The Devon Partnership Trust was candid and open regarding their considerable difficulties in this regard, that have been worsening over a number of years. Currently the Court was advised that a block booking of beds has been secured in the North Somerset region, but this short term solution is financially unsustainable, and not a good solution in term of patient need and geographical location. It is accepted that the problem of psychiatric in-patient beds is a national one , but on this occasion, had a bed been available when needed for Wendy, her death is likely to have been avoided.
The Court was advised that much of the difficulty is delayed discharge of patients, and it is acknowledged that this is a wider issue of social and community care and resources. This report is therefore being copied to the commissioners as well for their further consideration of the current untenable situation.
” 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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly apply the Mental Health Act in physical care environments
Wider context from the report “(1) It was recognised at inquest that there is a frequent need for patients with significant mental health needs to increasingly be cared for in a physical care environment, due to concurrent physical and mental health needs, and due to an increasing difficulty in sourcing psychiatric beds, which often requires a wait on a general ward. It was also acknowledged that the training of the physical healthcare staff "needs to improve", although it must be said that efforts have been made and are continuing to address this issue.
From the evidence there was clear confusion regarding the application of the Mental Health Act in the physical care environment , which led in this case to Wendy being allowed to leave the ward unaccompanied and without transport, which could have been avoided with better understanding of the available restrictive legislation.
” 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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in discharge caused by inadequate social and community care resources
Wider context from the report “(2) Wendy was to be admitted to a psychiatric bed at one stage of this final hospital stay, but she could not be transferred immediately due to the lack of beds. The Devon Partnership Trust was candid and open regarding their considerable difficulties in this regard, that have been worsening over a number of years. Currently the Court was advised that a block booking of beds has been secured in the North Somerset region, but this short term solution is financially unsustainable, and not a good solution in term of patient need and geographical location. It is accepted that the problem of psychiatric in-patient beds is a national one, but on this occasion, had a bed been available when needed for Wendy, her death is likely to have been avoided.
The Court was advised that much of the difficulty is delayed discharge of patients , and it is acknowledged that this is a wider issue of social and community care and resources . This report is therefore being copied to the commissioners as well for their further consideration of the current untenable situation.
” 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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate mental health training for physical healthcare staff
Wider context from the report “(1) It was recognised at inquest that there is a frequent need for patients with significant mental health needs to increasingly be cared for in a physical care environment, due to concurrent physical and mental health needs, and due to an increasing difficulty in sourcing psychiatric beds, which often requires a wait on a general ward. It was also acknowledged that the training of the physical healthcare staff "needs to improve" , although it must be said that efforts have been made and are continuing to address this issue.
From the evidence there was clear confusion regarding the application of the Mental Health Act in the physical care environment, which led in this case to Wendy being allowed to leave the ward unaccompanied and without transport, which could have been avoided with better understanding of the available restrictive legislation.
” Open source report
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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 Work with Devon County Council on care-home commissioning and market sufficiency for older people.
Verbatim wording from the response “9. NEW Devon CCG is working closely with Devon County Council with regard to care home commissioning and market sufficiency for older people.” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
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 Participate in workshops mapping current and future discharge and panel-approval processes.
Verbatim wording from the response “5. NEW Devon CCG, with Devon County Council representatives have participated in a series of workshops facilitated by DPT aimed at mapping current and future discharge and panel approval processes. NEW Devon CCG is awaiting the final report and recommendations for improvement in these processes from DPT;” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
Open published response
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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 Work with DPT to identify solutions for additional step-down bed capacity in Exeter.
Verbatim wording from the response “7. DPT have indicated a need for additional step down beds to be made available in the Exeter area and NEW Devon CCG is working with DPT to identify solutions for this need;” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
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 Offer DPT additional management and consultative support from the urgent-care commissioning team.
Verbatim wording from the response “8. NEW Devon CCG has offered DPT additional management and consultative support from its urgent care commissioning team who have had success in working with acute hospital providers to reduce delays in discharge;” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
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 Lead work with Devon County Council to streamline joint-funding approval processes and develop a simplified section 117 aftercare funding agreement.
Verbatim wording from the response “6. NEW Devon CCG is already leading a process, working in partnership with Devon County Council to streamline current processes for the approval of joint funding of s117 aftercare and are working towards a simplified s117 aftercare funding agreement;” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
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 Monitor delayed-discharge performance through regional board oversight and the DPT contract review meeting.
Verbatim wording from the response “Monitoring of timely discharge performance data” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
Open published response
Concerns raised 6 Inadequate staff training on responsibility for patient contact View source Failure to ensure staff-led contact for patients with severe mental health conditions View source Lack of adequate post-discharge mental health care and contact View source Failure of effective and robust duty system arrangements View source Failure of an effective and robust buddying system View source Unavailability of female psychiatric intensive care beds in Devon View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Louise Turner · 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
Louise Turner died on 27 June 2014 from inhalation of helium after recently being discharged from a lengthy inpatient stay while receiving treatment for a serious mental health illness. The report raised concerns about inadequate post-discharge care and contact, ineffective duty and buddying arrangements, expectations that patients initiate contact, and the absence of female intensive psychiatric care beds in Devon.
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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training on responsibility for patient contact
Wider context from the report “(3) There was a suggestion at Inquest that the patients themselves were expected to be in charge of making contact. In cases of severe mental health, this does not appear to be appropriate or realistic, and the Devon Partnership Trust should reconsider this and/or the training of their staff who hold this belief .
” 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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff-led contact for patients with severe mental health conditions
Wider context from the report “(3) There was a suggestion at Inquest that the patients themselves were expected to be in charge of making contact . In cases of severe mental health, this does not appear to be appropriate or realistic , and the Devon Partnership Trust should reconsider this and/or the training of their staff who hold this belief.
” 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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate post-discharge mental health care and contact
Wider context from the report “(1) The Devon Partnership trust had no adequate mental health care for Louise after she was discharged . There was inadequate contact and no explanation at Inquest as to why this had not taken place.
” 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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of effective and robust duty system arrangements
Wider context from the report “(2) The duty system arrangements and buddying system referred to at Inquest were not effective or robust and need to be reconsidered in the light of the outcome of this case.
” 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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of an effective and robust buddying system
Wider context from the report “(2) The duty system arrangements and buddying system referred to at Inquest were not effective or robust and need to be reconsidered in the light of the outcome of this case.
” 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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of female psychiatric intensive care beds in Devon
Wider context from the report “(4) There are no female intensive care beds for psychiatric patients in Devon . This does not match the desired parity of mental health care with physical health care. Devon Partnership Trust needs to consider future planning and provision to ensure the needs of patients can be met.
” 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 Lead an option appraisal with Peninsula commissioners and providers to identify the need for a Devon psychiatric intensive care unit.
Verbatim wording from the response “Following the publication of the Mental Health Crisis Care Concordat and the Care Quality Commission (CQC) inspection report into Devon Partnership NHS Trust in February 2014, it was identified that the lack of a Psychiatric Intensive Care Unit (PICU) in Devon was a significant deficit to the mental health acute care system. This was further magnified by the publication of the Crisp Report (Crisp, N., Smith, G. and Nicholson, K. (Eds.) Old Problems, New Solutions – Improving Acute Psychiatric Care) which identified serious issues with the use of out of area placements for people experiencing acute mental ill health.” Source location 2016-0322-Response-by-Northern-Eastern-and-Western-Devon-Clinical-Commissioning-Group
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 Review and agree a proposal for a 10-bed psychiatric intensive care unit on the Wonford Hospital site.
Verbatim wording from the response “The CCG led an option appraisal including all the Peninsula commissioners and providers, where it was identified that a PICU was required in Devon. This proposal was considered by the CCG and it was concluded that the revenue funding to support the operation of a PICU was available within the Devon Partnership NHS Trust contract and that they should develop a plan for the design, construction and operation of a PICU within Devon to ensure provision across Devon, Plymouth and Torbay. A proposal to build a local PICU facility was reviewed and agreed by the CCG Executive Committee on 20 July 2016 with the Governing Body confirming their support for implementation for a local, 10 bedded PICU on the Wonford Hospital site, adjacent to the Cedars Mental Health Acute Unit by April 2018.” Source location 2016-0322-Response-by-Northern-Eastern-and-Western-Devon-Clinical-Commissioning-Group
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 Devon Partnership NHS Trust should develop the plan for designing, constructing and operating the local psychiatric intensive care unit.
Verbatim wording from the response “The CCG led an option appraisal including all the Peninsula commissioners and providers, where it was identified that a PICU was required in Devon. This proposal was considered by the CCG and it was concluded that the revenue funding to support the operation of a PICU was available within the Devon Partnership NHS Trust contract and that they should develop a plan for the design, construction and operation of a PICU within Devon to ensure provision across Devon, Plymouth and Torbay. A proposal to build a local PICU facility was reviewed and agreed by the CCG Executive Committee on 20 July 2016 with the Governing Body confirming their support for implementation for a local, 10 bedded PICU on the Wonford Hospital site, adjacent to the Cedars Mental Health Acute Unit by April 2018.” Source location 2016-0322-Response-by-Northern-Eastern-and-Western-Devon-Clinical-Commissioning-Group
Open published response
Concerns raised 1 Failure to ensure clear information sharing for vulnerable adults at risk of self-neglect when their primary carer is outside the Clinical Commissioning Group 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
Andrew John Nickolls · 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
Andrew John Nickolls was discharged from Torbay Hospital on 12 September 2013 and was later found by police officers in his flat after concerns were raised. The report identified concerns about information sharing and continuity of primary care for a vulnerable adult who may have been neglecting himself; the medical cause of death was unascertained and the inquest conclusion was open.
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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clear information sharing for vulnerable adults at risk of self-neglect when their primary carer is outside the Clinical Commissioning Group
Wider context from the report “The principal learning point is to be that there is an advantage in a patient being looked after by a primary carer (i.e. a GP) within the Clinical Commissioning Group. If this is not the case, then it is imperative that there is clear information sharing, particularly where there is a vulnerable adult and there is a possibility they are neglecting themselves.
” Open source report
Concerns raised 4 Failure to provide locally accessible child psychiatric inpatient care View source Insufficient availability of child psychiatric inpatient beds View source Ineffective multidisciplinary CPA meeting participation and communication View source Lack of an effective bed bureau system for identifying child psychiatric bed spaces View source See 1 more concern
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
George Christian Werb · 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
George Christian Werb was receiving inpatient treatment for serious mental health issues and died after walking onto a railway track near his home while on home leave. The report raises concerns about the distant placement, inadequate risk assessment, poor communication and engagement with the family, and insufficient local child psychiatric beds.
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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide locally accessible child psychiatric inpatient care
Wider context from the report “(1) The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed. There was not at the time, and still appears to be no, or no effective bed bureau system to identify spaces. This is wasteful of clinician time, creates inevitable delays and is indicative that there are routinely too few available beds to serve the needs of our child psychiatric patients.
(2) On a previous admission during May 2014 the bed located was in Hurncombe, and George was removed by his father as the bedroom had inadequate furniture, had no bed linen and there was concern the environment was adding to George’s distress. The distance between home and this placement was in excess of 3 hours travel time.
(3) On the index admission, George was placed in the Priory Hospital, Southampton, a distance of over 2 hours travelling time from home. This is not an NHS facility and is specifically for “overflow” patients from all across England, many of whom are therefore huge distances from their home, their family, their friends and community support.
(4) Due to the distance, the hospital made the decision that family therapy could not take place (although the parents would have engaged if the importance of this was explained) and periods of home leave were extended due to travelling times, rather than in response to clinical need.
(5) There was poor attendance at the CPA meeting, and both parents and the community team only “attended” by telephone, which was far from ideal and impacted on the effectiveness of communication between all parties.
(6) Having local accessibility where in patient care is required was recognized in the Mental Health Crisis Care Concordat published 18 February 2014 to be important to keep the young person close to home, school and friends and this was also recognized by all the clinicians at request to be important and necessary. With current provision of beds this need is not being met, and is impacting on patient care.
(7) In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death.
” 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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of child psychiatric inpatient beds
Wider context from the report “(1) The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed. There was not at the time, and still appears to be no, or no effective bed bureau system to identify spaces. This is wasteful of clinician time, creates inevitable delays and is indicative that there are routinely too few available beds to serve the needs of our child psychiatric patients.
(2) On a previous admission during May 2014 the bed located was in Hurncombe, and George was removed by his father as the bedroom had inadequate furniture, had no bed linen and there was concern the environment was adding to George’s distress. The distance between home and this placement was in excess of 3 hours travel time.
(3) On the index admission, George was placed in the Priory Hospital, Southampton, a distance of over 2 hours travelling time from home. This is not an NHS facility and is specifically for “overflow” patients from all across England, many of whom are therefore huge distances from their home, their family, their friends and community support.
(4) Due to the distance, the hospital made the decision that family therapy could not take place (although the parents would have engaged if the importance of this was explained) and periods of home leave were extended due to travelling times, rather than in response to clinical need.
(5) There was poor attendance at the CPA meeting, and both parents and the community team only “attended” by telephone, which was far from ideal and impacted on the effectiveness of communication between all parties.
(6) Having local accessibility where in patient care is required was recognized in the Mental Health Crisis Care Concordat published 18 February 2014 to be important to keep the young person close to home, school and friends and this was also recognized by all the clinicians at request to be important and necessary. With current provision of beds this need is not being met , and is impacting on patient care.
(7) In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death.
” 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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Ineffective multidisciplinary CPA meeting participation and communication
Wider context from the report “(1) The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed. There was not at the time, and still appears to be no, or no effective bed bureau system to identify spaces. This is wasteful of clinician time, creates inevitable delays and is indicative that there are routinely too few available beds to serve the needs of our child psychiatric patients.
(2) On a previous admission during May 2014 the bed located was in Hurncombe, and George was removed by his father as the bedroom had inadequate furniture, had no bed linen and there was concern the environment was adding to George’s distress. The distance between home and this placement was in excess of 3 hours travel time.
(3) On the index admission, George was placed in the Priory Hospital, Southampton, a distance of over 2 hours travelling time from home. This is not an NHS facility and is specifically for “overflow” patients from all across England, many of whom are therefore huge distances from their home, their family, their friends and community support.
(4) Due to the distance, the hospital made the decision that family therapy could not take place (although the parents would have engaged if the importance of this was explained) and periods of home leave were extended due to travelling times, rather than in response to clinical need.
(5) There was poor attendance at the CPA meeting, and both parents and the community team only “attended” by telephone, which was far from ideal and impacted on the effectiveness of communication between all parties.
(6) Having local accessibility where in patient care is required was recognized in the Mental Health Crisis Care Concordat published 18 February 2014 to be important to keep the young person close to home, school and friends and this was also recognized by all the clinicians at request to be important and necessary. With current provision of beds this need is not being met, and is impacting on patient care.
(7) In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death.
” 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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective bed bureau system for identifying child psychiatric bed spaces
Wider context from the report “(1) The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed. There was not at the time, and still appears to be no, or no effective bed bureau system to identify spaces. This is wasteful of clinician time, creates inevitable delays and is indicative that there are routinely too few available beds to serve the needs of our child psychiatric patients.
(2) On a previous admission during May 2014 the bed located was in Hurncombe, and George was removed by his father as the bedroom had inadequate furniture, had no bed linen and there was concern the environment was adding to George’s distress. The distance between home and this placement was in excess of 3 hours travel time.
(3) On the index admission, George was placed in the Priory Hospital, Southampton, a distance of over 2 hours travelling time from home. This is not an NHS facility and is specifically for “overflow” patients from all across England, many of whom are therefore huge distances from their home, their family, their friends and community support.
(4) Due to the distance, the hospital made the decision that family therapy could not take place (although the parents would have engaged if the importance of this was explained) and periods of home leave were extended due to travelling times, rather than in response to clinical need.
(5) There was poor attendance at the CPA meeting, and both parents and the community team only “attended” by telephone, which was far from ideal and impacted on the effectiveness of communication between all parties.
(6) Having local accessibility where in patient care is required was recognized in the Mental Health Crisis Care Concordat published 18 February 2014 to be important to keep the young person close to home, school and friends and this was also recognized by all the clinicians at request to be important and necessary. With current provision of beds this need is not being met, and is impacting on patient care.
(7) In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death.
” Open source report
Concerns raised 3 Failure to ensure awareness of medication dangers when ingested by others View source Failure to secure medication View source Prescribing medication in quantities sufficient for a fatal dose 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
Andrew john Hooper · 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
Andrew John Hooper died after taking methadone prescribed to his girlfriend, with the stated cause of death being respiratory failure, hypoxic brain injury and methadone toxicity. The concerns were that the medication was not secured, was available in a quantity sufficient for a fatal dose, and that the person prescribed it appeared unaware of the risks to others and unable to keep it safe.
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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure awareness of medication dangers when ingested by others
Wider context from the report “(1) The medication was not secured, and was prescribed in sufficient quantity for a fatal dose to be taken by a user un-used to this medication. (bottle 420ml)
(2) the person to whom was prescribed appeared to be unaware of the dangers of this medication, when taken by another in large quantities .
(3) Consideration should be given to the appropriateness of prescribing to an individual who is not able or prepared to keep the medication safe and secure, or is not aware of the dangers of ingestion, (deliberate or otherwise), for others. If this means daily prescription, the balance of inconvenience versus the safety of others should be carefully weighed on an individual basis, and evidence recorded in this regard.
” 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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to secure medication
Wider context from the report “(1) The medication was not secured , and was prescribed in sufficient quantity for a fatal dose to be taken by a user un-used to this medication. (bottle 420ml)
(2) the person to whom was prescribed appeared to be unaware of the dangers of this medication, when taken by another in large quantities.
(3) Consideration should be given to the appropriateness of prescribing to an individual who is not able or prepared to keep the medication safe and secure, or is not aware of the dangers of ingestion, (deliberate or otherwise), for others. If this means daily prescription, the balance of inconvenience versus the safety of others should be carefully weighed on an individual basis, and evidence recorded in this regard.
” 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 NHS Devon Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Prescribing medication in quantities sufficient for a fatal dose
Wider context from the report “(1) The medication was not secured, and was prescribed in sufficient quantity for a fatal dose to be taken by a user un-used to this medication . (bottle 420ml)
(2) the person to whom was prescribed appeared to be unaware of the dangers of this medication, when taken by another in large quantities.
(3) Consideration should be given to the appropriateness of prescribing to an individual who is not able or prepared to keep the medication safe and secure, or is not aware of the dangers of ingestion, (deliberate or otherwise), for others. If this means daily prescription, the balance of inconvenience versus the safety of others should be carefully weighed on an individual basis, and evidence recorded in this regard.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations