Recipient

NHS Kernow Clinical Commissioning Group

First report 7 Aug 2015•Latest report 11 Feb 2019

Recipient record

Reports, concerns and published responses

Health and care · Clinical commissioning group. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 3
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 NHS Kernow Clinical Commissioning Group linked to the concerns in each report. Select any concern, action or position to view the source wording.

11 Feb2019
Cornwall and Isles of Scilly
Concerns raised4
1. Failure to develop and implement the delivery plan in relation to the existing CMHT-Addaction service level agreement
2. Failure of the working relationship between CMHT and Addaction
3. Failure to operate the Cornwall dual diagnosis policy effectively
1. Inadequate interface between Addaction and community mental-health teams
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 MATTHEW GILLAM · 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 Matthew Gillam was found dead at home after consuming alcohol, drugs and six pills of unknown composition. The inquest recorded that he died on 3 June 2018 from the toxic effects of a reckless overdose of non-prescription drugs. The principal concerns related to communication and working arrangements between Addaction and the Community Mental Health Team (CMHT), including the implementation of their service-level agreement and delivery plan.

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 Kernow Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation
Failure to develop and implement the delivery plan in relation to the existing CMHT-Addaction service level agreement
Wider context from the report
“(2) The development and implementation of the delivery plan in relation to the existing service level agreement between CMHT and Addaction. ”
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 Kernow Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation
Failure of the working relationship between CMHT and Addaction
Wider context from the report
“(3) The working relationship between CMHT and Addaction. ”
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 Kernow Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation
Failure to operate the Cornwall dual diagnosis policy effectively
Wider context from the report
“(1) The operation of the Cornwall dual diagnosis policy and the interface between Addaction and CMHT. ”
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 Kernow Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation
Inadequate interface between Addaction and community mental-health teams
Wider context from the report
“(1) The operation of the Cornwall dual diagnosis policy and the interface between Addaction and CMHT. ”
Open source report
6 Apr2018
Cornwall and Isles of Scilly
Concerns raised2
1. Deficiencies in aftercare or transition arrangements for patients discharged home at moderate to high risk of self-harm or suicide
2. Failure to put in place contact arrangements for patients discharged home at moderate to high risk of self-harm or suicide
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

Miriam Roach · 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

Miriam Roach, who had a history of depression, anxiety, alcohol dependency and self-harm, was discharged from hospital on 30 June 2017 after assessment following an overdose. She died by suicide on 1 July 2017 by hanging. The substantive concerns related to aftercare and the absence of arrangements to contact patients discharged home with moderate to high risks of self-harm or suicide.

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 Kernow Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation
Deficiencies in aftercare or transition arrangements for patients discharged home at moderate to high risk of self-harm or suicide
Wider context from the report
“(1) Regarding the aftercare or transition arrangements for those discharged from hospital to home with a moderate to high risk of self-harm and/or suicide following incidents of self-harm or suicide. (2) Specifically the obligations for putting in place contact arrangements for such patients. ”
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 Kernow Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation
Failure to put in place contact arrangements for patients discharged home at moderate to high risk of self-harm or suicide
Wider context from the report
“(1) Regarding the aftercare or transition arrangements for those discharged from hospital to home with a moderate to high risk of self-harm and/or suicide following incidents of self-harm or suicide. (2) Specifically the obligations for putting in place contact arrangements for such patients. ”
Open source report
7 Aug2015
Cornwall
Concerns raised2
1. Lack of acute psychiatric beds in Cornwall
2. Failure to staff designated mental health places of safety to the appropriate level
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

James Reuben Maxwell Adams · 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

James Adams was found dead at home on 10 August 2012 with a plastic bag and helium cylinders, and suicide notes were found nearby. He had persistent depressive disorder, alcohol dependency and a mixed type personality disorder, and was being treated by mental health services. Concerns included the police response to a welfare concern, information sharing, shortages of acute psychiatric beds, and inadequate staffing at designated mental health places of safety.

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 Kernow Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation
Lack of acute psychiatric beds in Cornwall
Wider context from the report
“The inquest heard how lessons had been learnt from the inquest and that the working relationship with the Devon and Cornwall Police and the local Mental Health Services (provided by Cornwall Partnership NHS Foundation Trust) had been improved and formalised through appropriate protocols and Memorandum of Understanding. One continuing difficulty was the “lack of acute psychiatric beds” in Cornwall. In addition, the police had found that on a regular basis, the designated mental health places of safety were not staffed to the appropriate level and the patient could not be left there. The result of this was that patients were being inappropriately detained in police cells by way of a safety net or were regularly being transported out of County as far as Manchester and Bournemouth to access the appropriate acute mental health bed. Cornwall Partnership NH Foundation Trust representative advised the Coroner that Cornwall has pro-rata less acute mental health beds than the national average. The preferred option for the mental health professionals was to treat local patients locally where they are known or are able to build up relationships with the local mental health team which is something that cannot happen if the patient is transported out of County. Further, the treating Psychiatrist is required to travel to the out of county unit to review the patient which results in valuable Consultant time not being available to local patients which may need access to them at a critical time. The result of this is that unnecessary stress is put on patients which can result in a deterioration of the patients mental health (and possibility death) at a time when the patient needs increased support and treatment. ”
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 Kernow Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation
Failure to staff designated mental health places of safety to the appropriate level
Wider context from the report
“The inquest heard how lessons had been learnt from the inquest and that the working relationship with the Devon and Cornwall Police and the local Mental Health Services (provided by Cornwall Partnership NHS Foundation Trust) had been improved and formalised through appropriate protocols and Memorandum of Understanding. One continuing difficulty was the “lack of acute psychiatric beds” in Cornwall. In addition, the police had found that on a regular basis, the designated mental health places of safety were not staffed to the appropriate level and the patient could not be left there. The result of this was that patients were being inappropriately detained in police cells by way of a safety net or were regularly being transported out of County as far as Manchester and Bournemouth to access the appropriate acute mental health bed. Cornwall Partnership NH Foundation Trust representative advised the Coroner that Cornwall has pro-rata less acute mental health beds than the national average. The preferred option for the mental health professionals was to treat local patients locally where they are known or are able to build up relationships with the local mental health team which is something that cannot happen if the patient is transported out of County. Further, the treating Psychiatrist is required to travel to the out of county unit to review the patient which results in valuable Consultant time not being available to local patients which may need access to them at a critical time. The result of this is that unnecessary stress is put on patients which can result in a deterioration of the patients mental health (and possibility death) at a time when the patient needs increased support and treatment. ”
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 raised4

Failure to develop and implement the delivery plan in relation to the existing CMHT-Addaction service level agreement

Failure of the working relationship between CMHT and Addaction

Failure to operate the Cornwall dual diagnosis policy effectively

Inadequate interface between Addaction and community mental-health teams

Concerns raised2

Deficiencies in aftercare or transition arrangements for patients discharged home at moderate to high risk of self-harm or suicide

Failure to put in place contact arrangements for patients discharged home at moderate to high risk of self-harm or suicide

Concerns raised2

Lack of acute psychiatric beds in Cornwall

Failure to staff designated mental health places of safety to the appropriate level