Recipient

Torbay and South Devon NHS Foundation Trust

First report 16 Dec 2019•Latest report 6 Feb 2026

Recipient record

Reports, concerns and published responses

Health and care · NHS trust. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 3
Published responses: 133%
Concerns addressed: 8
Stated actions: 30

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.

133%published responses found

30stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Torbay and South Devon NHS Foundation Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

6 Feb2026
Devon, Plymouth and Torbay
Concerns raised4
1. Lack of a process for recording Datix referrals made by other organisations
2. Lack of staff training and understanding of responsibility to report and escalate serious clinical incidents
3. Lack of understanding of when Serious Incident Reports should be made or actioned retrospectively
1. Lack of effective clinical-note review to identify unrecognised or unreported clinical issues
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 11
1. Action
  Commence quarterly learning events with incident reporting as a core topic.
  Stated planned
2. Action
  Deliver additional community-hospital training and targeted communications reinforcing incident-reporting expectations.
  Stated completed
3. Action
  Recruit and establish three Care Group Director of Nursing roles to lead governance and support patient safety.
  Stated completed
1. Action
  Update and publish the Trust PSIRF policy and plan to reflect new patient-safety insight data.
  Stated completed
2. Action
  Use the LfPSE-compliant reporting system to support cross-organisational routing of incidents to the relevant organisation.
  Stated completed
3. Action
  Use Medical Examiner reviews to systematically examine deaths and associated records, report concerns to DCIQ, and request structured judgement reviews where care may have contributed.
  Stated completed
4. Action
  Adopt PSIRF and operate weekly Executive Incident Review Meetings to determine proportionate investigation responses, including retrospective incidents.
  Stated completed
5. Action
  Review structured judgement review scores through care-group governance and executive meetings to determine further patient-safety investigation.
  Stated completed
6. Action
  Deliver incident-reporting education and training for clinical staff, including medical staff and new starters.
  Stated completed
7. Action
  Operate a process to receive external incident referrals, log them on DCIQ where needed, route them for investigation, and share outcomes with reporting organisations.
  Stated completed
8. Action
  Implement DCIQ as the Trust incident-reporting system and communicate that all staff may report unexpected or unintended incidents.
  Stated completed
AI-generated summary

Linda Brooks · 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

Linda Brooks, a 78-year-old care-home resident with respiratory and other comorbidities, was admitted after a fall and later died at Torbay Hospital on 17 May 2022. The inquest identified concerns about oxygen being switched off for an unknown period before her death, and about failures to report, investigate, escalate, and record the incident and related Datix referrals.

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 Torbay and South Devon NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of a process for recording Datix referrals made by other organisations
Wider context from the report
“4. There appeared to be no process for recording the fact that another organisation such as SWAST had made a Datix referral which would then have mitigated the fact that the SWAST Team failed to pass on their own DATIX to Torbay and South Devon NHS Trust. ”
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 Torbay and South Devon NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of staff training and understanding of responsibility to report and escalate serious clinical incidents
Wider context from the report
“1. There appeared to be a lack of training and understanding by staff at the Trust that it is everybody’s responsibility to report and escalate a serious clinical incident such as this ”
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 Torbay and South Devon NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of understanding of when Serious Incident Reports should be made or actioned retrospectively
Wider context from the report
“3. There appears to be a lack of understanding as to when a Serious Incident Report should be made or actioned retrospectively ”
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 Torbay and South Devon NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of effective clinical-note review to identify unrecognised or unreported clinical issues
Wider context from the report
“2. There appears to be no effective process in place for reviewing clinical notes to pick up a clinical issue such as this in circumstances where no complaint has been made by a family member, and no member of staff has recognised or reported it . ”
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
Commence quarterly learning events with incident reporting as a core topic.

Verbatim wording from the response
“Since the inquest, additional community-hospital training and targeted communications have been delivered to reinforce incident reporting expectations, and a quarterly learning event programme will commence from June with incident reporting as a core topic. Effectiveness is monitored by the central Patient Safety Team through DCIQ reporting volumes and training compliance, reviewed monthly via PSIRG and escalated through care group governance where required.”

Source location
2026-0085 - Response from Torbay and South Devon NHS Trust
Page 4 · response
Published 13 February 2026
Open published response
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
Deliver additional community-hospital training and targeted communications reinforcing incident-reporting expectations.

Verbatim wording from the response
“Since the inquest, additional community-hospital training and targeted communications have been delivered to reinforce incident reporting expectations, and a quarterly learning event programme will commence from June with incident reporting as a core topic. Effectiveness is monitored by the central Patient Safety Team through DCIQ reporting volumes and training compliance, reviewed monthly via PSIRG and escalated through care group governance where required.”

Source location
2026-0085 - Response from Torbay and South Devon NHS Trust
Page 4 · response
Published 13 February 2026
Open published response
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
Recruit and establish three Care Group Director of Nursing roles to lead governance and support patient safety.

Verbatim wording from the response
“To ensure it is everybody’s responsibility to report and escalate serious patient safety incidents, the Trust has strengthened its patient safety governance, training, and reporting infrastructure.”

Source location
2026-0085 - Response from Torbay and South Devon NHS Trust
Page 3 · response
Published 13 February 2026
Open published response
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
Update and publish the Trust PSIRF policy and plan to reflect new patient-safety insight data.

Verbatim wording from the response
“The Trust PSIRF policy and plan is available to access on the internet and was updated in January 2026 following new safety insight data. Effectiveness is monitored by the EIRM through review of all moderate-or-above incidents and confirmation of agreed investigation route and completion, reviewed weekly with actions tracked through care group governance.”

Source location
2026-0085 - Response from Torbay and South Devon NHS Trust
Page 5 · response
Published 13 February 2026
Open published response
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
Use the LfPSE-compliant reporting system to support cross-organisational routing of incidents to the relevant organisation.

Verbatim wording from the response
“In addition, the Trust’s incident reporting system is compliant with the national Learning from Patient Safety Events (LfPSE) service, supporting cross-organisational routing of incident reports where the incident occurred in another organisation.”

Source location
2026-0085 - Response from Torbay and South Devon NHS Trust
Page 6 · response
Published 13 February 2026
Open published response
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
Use Medical Examiner reviews to systematically examine deaths and associated records, report concerns to DCIQ, and request structured judgement reviews where care may have contributed.

Verbatim wording from the response
“To ensure clinical issues are identified even when no complaint is raised, the Trust now uses the Medical Examiner (ME) review process to systematically review deaths and associated records.”

Source location
2026-0085 - Response from Torbay and South Devon NHS Trust
Page 4 · response
Published 13 February 2026
Open published response
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
Adopt PSIRF and operate weekly Executive Incident Review Meetings to determine proportionate investigation responses, including retrospective incidents.

Verbatim wording from the response
“To clarify when incidents require investigation (including retrospectively), the Trust has adopted PSIRF and uses a weekly Executive Incident Review Meeting (EIRM) to determine and govern the appropriate response.”

Source location
2026-0085 - Response from Torbay and South Devon NHS Trust
Page 5 · response
Published 13 February 2026
Open published response
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
Review structured judgement review scores through care-group governance and executive meetings to determine further patient-safety investigation.

Verbatim wording from the response
“These are then reviewed by governance leads in the care group and scored on the DCIQ SJR system, with any scoring 1 or 2 triggering being considered for further investigation. These structured judgment reviews will be considered at the weekly executive review meeting for consideration of a more detailed patient safety review or patient safety incident investigation in line with local and National PSIRF priorities. Effectiveness is monitored by the ME service and care group governance leads via completion of ME reviews and the number/timeliness of DCIQ submissions and SJRs, reviewed weekly at the Executive Incident Review Meeting (EIRM).”

Source location
2026-0085 - Response from Torbay and South Devon NHS Trust
Page 5 · response
Published 13 February 2026
Open published response
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
Deliver incident-reporting education and training for clinical staff, including medical staff and new starters.

Verbatim wording from the response
“These roles support our clinical staff with the reporting of incidents, including education and training sessions for clinical staff, including medical staff. We have also just recruited 3 new Care group Director of Nursing roles to lead governance within our care group structures and to support patient safety.”

Source location
2026-0085 - Response from Torbay and South Devon NHS Trust
Page 3 · response
Published 13 February 2026
Open published response
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
Operate a process to receive external incident referrals, log them on DCIQ where needed, route them for investigation, and share outcomes with reporting organisations.

Verbatim wording from the response
“To ensure incidents raised by partner organisations (e.g., SWAST) are reliably captured and actioned, the Trust operates a defined process to receive external referrals, log them on DCIQ where needed, and route them for investigation.”

Source location
2026-0085 - Response from Torbay and South Devon NHS Trust
Page 6 · response
Published 13 February 2026
Open published response
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
Implement DCIQ as the Trust incident-reporting system and communicate that all staff may report unexpected or unintended incidents.

Verbatim wording from the response
“A new reporting system [DCIQ] was implemented in the Trust in October 2023; the importance of reporting incidents formed a large part of the communication plan around this system.”

Source location
2026-0085 - Response from Torbay and South Devon NHS Trust
Page 4 · response
Published 13 February 2026
Open published response
28 Feb2024
Plymouth, Torbay and South Devon
Concerns raised3
1. Lack of clarity about the CQC’s role in oversight of personal care packages
2. Failure to review the need for policies ensuring independent providers carry out contractual duties towards vulnerable individuals
3. Failure to acknowledge safeguarding referrals and communicate action taken
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review and reissue provider contracts with updated quality standards and key performance indicators.
  Stated in progress
2. Action
  Conduct regular provider contract reviews and monitor service-level agreements and key performance indicators.
  Stated completed
Respondent positions 3
1. Position
  The individual received medication reminders and shopping assistance, not personal or domiciliary care; therefore the Trust understood there was no CQC role.
  Disputes the concern
1. Position
  Enhanced contract management, quality control, audits, provider reviews and welfare checks were considered sufficient to mitigate recurrence risk.
  Existing arrangements considered sufficient
2. Position
  The Disclosure and Barring Service concern could not be answered by the Trust and should be raised directly with that Service.
  Redirects responsibility
AI-generated summary

Adrian Stuart Green · 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

Adrian Stuart Green, aged 55, died at Torbay Hospital on 1 November 2021 from alcoholic liver disease after living at Whiteley Court, where he was supposed to receive assistance with medication, support and care, meals, and shopping. The inquest heard that he did not receive appropriate care or visits for several weeks and was found in squalid and unhygienic conditions in an almost unresponsive state. Concerns included whether the local authority had adequate policies for overseeing independent providers, the CQC’s role and jurisdiction, and the lack of acknowledgement or response to a Disclosure and Barring Service referral.

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 Torbay and South Devon NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of clarity about the CQC’s role in oversight of personal care packages
Wider context from the report
“(2) ████████ gave evidence to the inquest that she believed that there was a role for the CQC here as she believed that Mr Green had been in receipt of a personal care package ”
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 Torbay and South Devon NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to review the need for policies ensuring independent providers carry out contractual duties towards vulnerable individuals
Wider context from the report
“(1) Despite there being a safeguarding meeting following Mr. Green’s death on 22nd January 2022 there appeared to be no review of whether the local authority ought to have had policies in place to ensure that independent providers were adequately carrying out their contractual duties towards vulnerable individuals especially if the CQC were correct and there was no role for them in this case ”
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 Torbay and South Devon NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to acknowledge safeguarding referrals and communicate action taken
Wider context from the report
“(3) ████████ made a referral to the Disclosure and Barring service in respect of the former manager’s actions and received no response as to what action if any the service were taking or an acknowledgement of her concerns . ”
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
Review and reissue provider contracts with updated quality standards and key performance indicators.

Verbatim wording from the response
“3) The team are currently in the process of reviewing and re-issuing all contracts to include updated quality standards and key performance indicators within our service specifications (Doc 2)”

Source location
Response from Torbay and Devon NHS
Page 5 · response
Published 6 March 2024
Open published response
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
Conduct regular provider contract reviews and monitor service-level agreements and key performance indicators.

Verbatim wording from the response
“7) Contract Managers complete Contract Review Meetings on a regular basis with all providers (Doc 10).”

Source location
Response from Torbay and Devon NHS
Page 6 · response
Published 6 March 2024
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 individual received medication reminders and shopping assistance, not personal or domiciliary care; therefore the Trust understood there was no CQC role.

Verbatim wording from the response
“Prior to his death Adrian was residing in Whitley court (which was under the management of Care Support), and his assessed package of care was for 3 x per day support with medication and 3 x per week support with shopping. Adrian Green was not in receipt of any domiciliary care.”

Source location
Response from Torbay and Devon NHS
Page 3 · response
Published 6 March 2024
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
Enhanced contract management, quality control, audits, provider reviews and welfare checks were considered sufficient to mitigate recurrence risk.

Verbatim wording from the response
“Following Adrian Green’s death a full review and restructure of how contracts are managed and continually reviewed has been completed by Torbay and South Devon NHS Foundation Trust. The Trust now has a more robust system of contract management, quality control and audit in place which, we suggest, would mitigate the chances of another incident like this occurring. Regular contract review meetings take place with all care providers, all service level agreements are monitored including key performance indicators. A review of the interactions with service users and how many missed appointments a service user has had in this period is also assessed.”

Source location
Response from Torbay and Devon NHS
Page 9 · response
Published 6 March 2024
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 Disclosure and Barring Service concern could not be answered by the Trust and should be raised directly with that Service.

Verbatim wording from the response
“b) ████████ made a referral to the Disclosure and Barring service in respect of the former manager’s actions and received no response as to what action if any the service were taking or an acknowledgement of her concerns. Torbay and South Devon NHS Foundation Trust are unable to answer this concern and this should be raised directly with the Disclosure and Barring Service.”

Source location
Response from Torbay and Devon NHS
Page 9 · response
Published 6 March 2024
Open published response
16 Dec2019
Avon
Concerns raised1
1. Failure to refer patients with multiple developmental, sensory and physical conditions for investigation of an underlying disorder by a clinical geneticist
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Hold a paediatric meeting with the Regional Clinical Genetics Service to review referral guidance and disseminate it to the paediatric clinical teams.
  Stated planned
2. Action
  Assess paediatric clinicians’ individual needs for genetic-care updates and support any additional training costs.
  Stated planned
3. Action
  Establish a regular Regional Clinical Genetics advice point during or after monthly clinics.
  Stated planned
1. Action
  Review paediatric communication and care-coordination processes and recommend improvements to Trust governance groups.
  Stated planned
2. Action
  Provide Genomics nurse attendance at a paediatric departmental meeting to explain the Regional Genetic Service.
  Stated completed
3. Action
  Provide twice-yearly educational contact from the Regional Clinical Genetics Service at established paediatric clinical education meetings.
  Stated planned
AI-generated summary

Alice Marie Sloman · 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

Alice Marie Sloman died after a routine general anaesthetic for an MRI scan precipitated cardiac decompensation associated with an undiagnosed cardiomyopathy. The principal concern was that, despite multiple conditions and her parents’ requests, she was not referred for investigation of an underlying disorder, including a clinical geneticist’s opinion, and her serious cardiomyopathy therefore went undiagnosed.

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 Torbay and South Devon NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to refer patients with multiple developmental, sensory and physical conditions for investigation of an underlying disorder by a clinical geneticist
Wider context from the report
“The evidence demonstrated that Alice was under the care of a consultant community paediatrician, a consultant general paediatrician with an interest in endocrinology and a consultant paediatric endocrinologist presenting with a number of conditions (Growth hormone deficiency, Autistic Spectrum disorder, developmental delay, visual impairment, mobility impairment, poor coordination/dyspraxia and hypermobility) over a 4 year period but was not referred for investigation of an underlying disorder, specifically a clinical geneticist’s opinion, despite her parents requesting this on at least 2 separate occasions which are documented and despite such facility being readily available in Exeter. The evidence demonstrated that as a result her underlying condition, and specifically a serious cardiomyopathy, went undiagnosed resulting in her dying unexpectedly and prematurely as a result of a routine general anaesthetic. ”
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 paediatric meeting with the Regional Clinical Genetics Service to review referral guidance and disseminate it to the paediatric clinical teams.

Verbatim wording from the response
“Detailed discussion has taken place since the findings of the inquest between the clinical leads of the Paediatric service at TSDFT and the lead clinician of the Regional Clinical Genetics Service in Exeter. A plan has been agreed to ensure that there is good understanding across the specialty of Paediatrics at TSDFT of the place of genetic testing in reaching a diagnosis where there are complex features. Actions include:”

Source location
2019-0442-Response-from-Torbay-and-South-Devon-NHS-Trust-Redacted
Page 2 · response
Published 3 January 2020
Open published response
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
Assess paediatric clinicians’ individual needs for genetic-care updates and support any additional training costs.

Verbatim wording from the response
“Action 7. Agreement that individual members of clinical teams consider their personal needs for update in relation to the genetic aspects of paediatric care. Any additional training and its cost will be supported by the Trust. Clinical Service Lead to assess completion by 1st May 2020.”

Source location
2019-0442-Response-from-Torbay-and-South-Devon-NHS-Trust-Redacted
Page 2 · response
Published 3 January 2020
Open published response
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
Establish a regular Regional Clinical Genetics advice point during or after monthly clinics.

Verbatim wording from the response
“Action 8. Establishment of a regular advice point during/after the monthly clinics undertaken by the Regional Clinical Genetics Service in TSDFT. Commencing May 2020. Lead Clinical Service Lead and Operational Manager for Paediatrics.”

Source location
2019-0442-Response-from-Torbay-and-South-Devon-NHS-Trust-Redacted
Page 2 · response
Published 3 January 2020
Open published response
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
Review paediatric communication and care-coordination processes and recommend improvements to Trust governance groups.

Verbatim wording from the response
“Communication between teams within the Trust and with local partners in care. It has been agreed that the clinicians responsible for investigating and supporting Alice did not have access to all the relevant information about her day to day problems that would have prompted consideration of further investigation, including referral to the Clinical Genetics service. The leads of the Paediatric service at TSDFT have undertaken to review the processes in place”

Source location
2019-0442-Response-from-Torbay-and-South-Devon-NHS-Trust-Redacted
Page 1 · response
Published 3 January 2020
Open published response
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
Provide Genomics nurse attendance at a paediatric departmental meeting to explain the Regional Genetic Service.

Verbatim wording from the response
“Detailed discussion has taken place since the findings of the inquest between the clinical leads of the Paediatric service at TSDFT and the lead clinician of the Regional Clinical Genetics Service in Exeter. A plan has been agreed to ensure that there is good understanding across the specialty of Paediatrics at TSDFT of the place of genetic testing in reaching a diagnosis where there are complex features. Actions include:”

Source location
2019-0442-Response-from-Torbay-and-South-Devon-NHS-Trust-Redacted
Page 2 · response
Published 3 January 2020
Open published response
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
Provide twice-yearly educational contact from the Regional Clinical Genetics Service at established paediatric clinical education meetings.

Verbatim wording from the response
“Action 6. A twice yearly educational contact at established clinical educational meetings held by the senior TSDFT Paediatric team starting on the 26th February and then in September 2020. Lead – Clinical Service Lead for Paediatrics.”

Source location
2019-0442-Response-from-Torbay-and-South-Devon-NHS-Trust-Redacted
Page 2 · response
Published 3 January 2020
Open published response

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

Reports, concerns and published responses

Reports over time

Concerns raised4

Lack of a process for recording Datix referrals made by other organisations

Lack of staff training and understanding of responsibility to report and escalate serious clinical incidents

Lack of understanding of when Serious Incident Reports should be made or actioned retrospectively

Lack of effective clinical-note review to identify unrecognised or unreported clinical issues

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.11

Concerns raised3

Lack of clarity about the CQC’s role in oversight of personal care packages

Failure to review the need for policies ensuring independent providers carry out contractual duties towards vulnerable individuals

Failure to acknowledge safeguarding referrals and communicate action taken

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.2

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.3

Concerns raised1

Failure to refer patients with multiple developmental, sensory and physical conditions for investigation of an underlying disorder by a clinical geneticist

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.6

Actions described in response 11

Actions described in response 2

Respondent positions 3

Actions described in response 6