13 Feb 2014 Professor John Elfed Davies · Prevention of Future Deaths report Inner West London
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Concerns raised 6 Failure to provide information about relevant support agencies to clinicians subject to investigative processes View source Failure to recognise adverse psychological effects in clinicians subject to investigative processes View source Lack of psychological support for clinicians subject to investigative processes View source Failure to facilitate appropriate on-ward referral for clinicians subject to investigative processes View source Failure to assess and identify suicidal or other self-harming behaviour in clinicians subject to investigative processes View source Failure to use appropriate language and tone in written communications with clinicians subject to investigative processes View source See 3 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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Professor John Elfed Davies · 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
Professor John Elfed Davies, aged 71, was found deceased in his hotel room on 10 June 2013 with self-inflicted incised wounds to his neck and multiple stab wounds to his chest. The inquest concluded that he took his own life, and a note indicated that GMC proceedings were playing on his mind. The principal concern was that doctors undergoing GMC investigations may experience unrecognised and unsupported adverse psychological effects, including suicidal or other self-harming behaviour.
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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 The Medical Protection Society Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide information about relevant support agencies to clinicians subject to investigative processes
Wider context from the report “This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practise has been found to play a part.
I am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported.
Consideration should be given to the language and tone of written communications, the provision of information about relevant support agencies , and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral.
” 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 The Medical Protection Society Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise adverse psychological effects in clinicians subject to investigative processes
Wider context from the report “This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practise has been found to play a part.
I am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported.
Consideration should be given to the language and tone of written communications, the provision of information about relevant support agencies, and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral.
” 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 The Medical Protection Society Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of psychological support for clinicians subject to investigative processes
Wider context from the report “This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practise has been found to play a part.
I am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported .
Consideration should be given to the language and tone of written communications, the provision of information about relevant support agencies, and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral.
” 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 The Medical Protection Society Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to facilitate appropriate on-ward referral for clinicians subject to investigative processes
Wider context from the report “This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practise has been found to play a part.
I am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported.
Consideration should be given to the language and tone of written communications, the provision of information about relevant support agencies, and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral .
” 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 The Medical Protection Society Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and identify suicidal or other self-harming behaviour in clinicians subject to investigative processes
Wider context from the report “This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practise has been found to play a part.
I am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported.
Consideration should be given to the language and tone of written communications, the provision of information about relevant support agencies, and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral.
” 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 The Medical Protection Society Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to use appropriate language and tone in written communications with clinicians subject to investigative processes
Wider context from the report “This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practise has been found to play a part.
I am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported.
Consideration should be given to the language and tone of written communications , the provision of information about relevant support agencies, and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral.
” 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