Recipient

Seaton and Colyton Medical Practice

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First report 2 Jun 2017•Latest report 2 Jun 2017

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. 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
100%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
2

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.

100%published responses found
2stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Seaton and Colyton Medical Practice linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Exeter and Greater Devon

    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 Seaton and Colyton Medical Practice; 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 Seaton and Colyton Medical Practice; 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

    Hold a formal Significant Event Audit to discuss the case and consider appropriate future care pathways for people with similar learning difficulties and medical problems.

    Verbatim wording from the response

    “The Seaton & Colyton Medical Practice held an informal Significant Event Audit Meeting following Jessica’s death, following which ████████ provided a report to the Coroner as requested. Following receipt of the Record of Inquest and taking particular regard to the Regulation 28: Report to Prevent Future Deaths, the practice will hold a formal Significant Event Audit Meeting in which we will discuss Jessica’s case and consider appropriate pathways for others in the future in a similar situation to Jessica to take into account any learning difficulties and associated medical problems.”

    Source location

    2016-0208-Response-by-The-Seaton-and-Colyton-Medical-Practice
    Page 2 · response
    Published 2 June 2016

    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

    The support services were equipped to care for someone with Jessica’s intellectual disabilities and were not inadequate as suggested.

    Verbatim wording from the response

    “Jessica sadly died on 28 July 2015 having taken an overdose. There is no reference in her primary care records that she expressed to her GP any thoughts of deliberate self-harm. I take note with regards to the “Matters of Concern” raised under Regulation 28. However, it is my opinion that Jessica was under the care of a consultant psychiatrist specialising in learning disabilities, the Devon Learning Disability Team and also the Depression and Anxiety Service, as had previously been arranged by two consultant psychiatrists. It is not, therefore, my view that the support services were not equipped to deal with someone of Jessica’s intellectual disabilities.”

    Source location

    2016-0208-Response-by-The-Seaton-and-Colyton-Medical-Practice
    Page 2 · response
    Published 2 June 2016

    Open published response
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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

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

How actions were described at the time

This respondent
100%
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