NHS South Devon and Torbay Clinical Commissioning Group

Health and care · Clinical commissioning group

Pin Request correction

First report 17 Jun 2015•Latest report 17 Jun 2015

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from NHS South Devon and Torbay Clinical Commissioning Group linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Plymouth, Torbay and South Devon

    AI-generated summary

    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 South Devon and Torbay Clinical Commissioning Group; 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
Back to top

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