2 Jun 2017 Jessica Mary BIRKHEAD · Prevention of Future Deaths report Exeter and Greater Devon
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Concerns raised 2 Lack of an appropriate care pathway for people with learning difficulties and associated medical problems View source Failure of mainstream adult support services to provide care for people with intellectual disabilities View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 1
Action
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.
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Jessica Mary BIRKHEAD · Prevention of Future Deaths report
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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.
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× 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
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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
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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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations