Concerns raised 8 Failure to communicate previous hoarding incidents to the GP View source Inconsistent reporting of absconding incidents View source Unclear escalation of absconding incidents to MDT review View source Failure of the system for monitoring compliance with prescribed medication View source Inadequate monitoring arrangements for residents with previous incidents of absconding View source Unclear reporting of seizure-related incidents to relevant bodies View source Failure to notify relevant professionals of doubt about medication compliance View source Failure to safely supervise bathing for residents with a known risk of seizure View source See 5 more concerns
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AI-generated summary
Dylan Jay Henty · 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
Dylan Jay Henty had a complex medical history including schizophrenia, a cerebral tumour, communication difficulties and seizures. He went missing after declining prescribed medication on 17 February 2018, and his body was found at Fistral beach on 21 February 2018; the cause of death was recorded as multiple injuries, with no evidence explaining the apparent fall or how he entered the sea. Concerns included an unsupervised seizure in a bath, inadequate awareness of hoarding, medication compliance, inconsistent reporting of absconding incidents, and arrangements for monitoring residents at risk of absconding.
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 Pentree Lodge; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate previous hoarding incidents to the GP
Wider context from the report “ii. Dylan’s GP was unaware of previous incidents of hoarding . He felt this was something that should have been brought to his attention . You may wish to reflect on the need for clear guidance and training to all staff in such matters. Similarly, you may wish to reflect on the need for those in management positions to ensure rigorous compliance with the relevant standards.
” 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 Pentree Lodge; that does not assign responsibility.
PFD Monitor interpretation Inconsistent reporting of absconding incidents
Wider context from the report “iv. There appeared to have been inconsistency in the reporting of incidents of absconding . You may wish to reflect on the need, in similar circumstances, for reports to be made to the GP, care coordinator and CQC . Further, you may wish to consider at what point there is a need for such matters to be considered at MDT level, for example, to consider whether current residential arrangements continue to be appropriate.
” 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 Pentree Lodge; that does not assign responsibility.
PFD Monitor interpretation Unclear escalation of absconding incidents to MDT review
Wider context from the report “iv. There appeared to have been inconsistency in the reporting of incidents of absconding. You may wish to reflect on the need, in similar circumstances, for reports to be made to the GP, care coordinator and CQC. Further, you may wish to consider at what point there is a need for such matters to be considered at MDT level , for example, to consider whether current residential arrangements continue to be appropriate .
” 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 Pentree Lodge; that does not assign responsibility.
PFD Monitor interpretation Failure of the system for monitoring compliance with prescribed medication
Wider context from the report “iii. Linked to the issue of hoarding is the question of how to ensure a resident is compliant with taking medication prescribed to him. It was accepted in evidence that, given the discovery of the medication in Dylan’s room, the system in place must have failed . It was recognised in court that there are limits to enforcing residents to take medication. Nevertheless, there needs to be a robust system in place and where there is doubt about a resident’s compliance, notification should be made to the relevant professionals.
” 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 Pentree Lodge; that does not assign responsibility.
PFD Monitor interpretation Inadequate monitoring arrangements for residents with previous incidents of absconding
Wider context from the report “v. Linked to the above are the arrangements put in place to monitor residents where there have been previous incidents of absconding . There needs to be a clear recognition of what is realistic particularly when set against the desire to ensure the Lodge remains the resident’s home.
” 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 Pentree Lodge; that does not assign responsibility.
PFD Monitor interpretation Unclear reporting of seizure-related incidents to relevant bodies
Wider context from the report “i. While it appears to have had no bearing on the circumstances of Dylan’s death, I was concerned to hear evidence of Dylan suffering a seizure in a bath while unsupervised. Similar episodes elsewhere in the country have resulted in criminal prosecutions. It is not clear to me whether reports were made to the CQC, GP and/or care coordinator . You may wish to reflect on the need for clear guidance and training to all staff on the arrangements for those residents with a known risk of seizure to take baths (as opposed to showers) where there is an obvious risk of drowning should a seizure occur. Similarly, those in management positions must be clear about the circumstances in which formal reports should be submitted to relevant bodies and you may feel there is a need to ensure these standards are rigorously checked and met.
” 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 Pentree Lodge; that does not assign responsibility.
PFD Monitor interpretation Failure to notify relevant professionals of doubt about medication compliance
Wider context from the report “iii. Linked to the issue of hoarding is the question of how to ensure a resident is compliant with taking medication prescribed to him. It was accepted in evidence that, given the discovery of the medication in Dylan’s room, the system in place must have failed. It was recognised in court that there are limits to enforcing residents to take medication. Nevertheless, there needs to be a robust system in place and where there is doubt about a resident’s compliance, notification should be made to the relevant professionals .
” 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 Pentree Lodge; that does not assign responsibility.
PFD Monitor interpretation Failure to safely supervise bathing for residents with a known risk of seizure
Wider context from the report “i. While it appears to have had no bearing on the circumstances of Dylan’s death, I was concerned to hear evidence of Dylan suffering a seizure in a bath while unsupervised . Similar episodes elsewhere in the country have resulted in criminal prosecutions. It is not clear to me whether reports were made to the CQC, GP and/or care coordinator. You may wish to reflect on the need for clear guidance and training to all staff on the arrangements for those residents with a known risk of seizure to take baths (as opposed to showers) where there is an obvious risk of drowning should a seizure occur . Similarly, those in management positions must be clear about the circumstances in which formal reports should be submitted to relevant bodies and you may feel there is a need to ensure these standards are rigorously checked and met.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations