Recipient

Recipient name withheld

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First report 17 Jan 2014•Latest report 17 Jan 2014

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

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

Reports over time

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 Recipient name withheld linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Cornwall

    AI-generated summary

    JULIA SHEEREN DELL · 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

    Julia Sheeren Dell, aged 45, took her own life after jumping from cliffs at Duckpool Beach and died of multiple injuries. The report identified concerns about limited primary-care contact after 4 April 2012, no formal handover between doctors, and no apparent action on a care plan received from the Community Mental Health Team.

    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of formal handover when primary care responsibility changed

    Wider context from the report

    “I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to ███████ and ███████ who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care. At inquest, ███████ conceded that: “it would have been nice for there to have been more involvement from primary care after 4 April 2012”. He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death. (1) There appears to have been no formal hand over between ████████ to ████████ in early April 2012. (2) On 19 April 2012 a care plan was received from the Community Mental Health Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her notwithstanding the fact that only three weeks previously on 22 March 2012 ████████ had contacted ████████ to express his concerns over Mrs Dell’s wellbeing ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to act on a care plan received from the Community Mental Health Team

    Wider context from the report

    “I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to ███████ and ███████ who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care. At inquest, ███████ conceded that: “it would have been nice for there to have been more involvement from primary care after 4 April 2012”. He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death. (1) There appears to have been no formal hand over between ████████ to ████████ in early April 2012. (2) On 19 April 2012 a care plan was received from the Community Mental Health Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her notwithstanding the fact that only three weeks previously on 22 March 2012 ████████ had contacted ████████ to express his concerns over Mrs Dell’s wellbeing ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of primary care to maintain involvement and awareness of fluctuating mood

    Wider context from the report

    “I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to ███████ and ███████ who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care. At inquest, ███████ conceded that: “it would have been nice for there to have been more involvement from primary care after 4 April 2012”. He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death. (1) There appears to have been no formal hand over between ████████ to ████████ in early April 2012. (2) On 19 April 2012 a care plan was received from the Community Mental Health Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her notwithstanding the fact that only three weeks previously on 22 March 2012 ████████ had contacted ████████ to express his concerns over Mrs Dell’s wellbeing ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to reconcile reassurance about mood stabilisation with recent concerns about wellbeing

    Wider context from the report

    “I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to ███████ and ███████ who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care. At inquest, ███████ conceded that: “it would have been nice for there to have been more involvement from primary care after 4 April 2012”. He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death. (1) There appears to have been no formal hand over between ████████ to ████████ in early April 2012. (2) On 19 April 2012 a care plan was received from the Community Mental Health Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her notwithstanding the fact that only three weeks previously on 22 March 2012 ████████ had contacted ████████ to express his concerns over Mrs Dell’s wellbeing ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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