Concerns raised 4 Lack of a process for recording Datix referrals made by other organisations View source Lack of staff training and understanding of responsibility to report and escalate serious clinical incidents View source Lack of understanding of when Serious Incident Reports should be made or actioned retrospectively View source Lack of effective clinical-note review to identify unrecognised or unreported clinical issues View source See 1 more concern
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
Action
Commence quarterly learning events with incident reporting as a core topic.
View source
Action
Deliver additional community-hospital training and targeted communications reinforcing incident-reporting expectations.
View source
Action
Recruit and establish three Care Group Director of Nursing roles to lead governance and support patient safety.
View source
Action
Update and publish the Trust PSIRF policy and plan to reflect new patient-safety insight data.
View source
Action
Use the LfPSE-compliant reporting system to support cross-organisational routing of incidents to the relevant organisation.
View source
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.
View source
Action
Adopt PSIRF and operate weekly Executive Incident Review Meetings to determine proportionate investigation responses, including retrospective incidents.
View source
Action
Review structured judgement review scores through care-group governance and executive meetings to determine further patient-safety investigation.
View source
Action
Deliver incident-reporting education and training for clinical staff, including medical staff and new starters.
View source
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.
View source
Action
Implement DCIQ as the Trust incident-reporting system and communicate that all staff may report unexpected or unintended incidents.
View source See 8 more actions
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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
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
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
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
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
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
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
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
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
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
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
Open published response
Concerns raised 3 Lack of clarity about the CQC’s role in oversight of personal care packages View source Failure to review the need for policies ensuring independent providers carry out contractual duties towards vulnerable individuals View source Failure to acknowledge safeguarding referrals and communicate action taken 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. 2
Action
Review and reissue provider contracts with updated quality standards and key performance indicators.
View source
Action
Conduct regular provider contract reviews and monitor service-level agreements and key performance indicators.
View source
×
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
Open published response
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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 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
Open published response
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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 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
Open published response
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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 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
Open published response
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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 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
Open published response
16 Dec 2019 Alice Marie Sloman · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Failure to refer patients with multiple developmental, sensory and physical conditions for investigation of an underlying disorder by a clinical geneticist 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. 6
Action
Hold a paediatric meeting with the Regional Clinical Genetics Service to review referral guidance and disseminate it to the paediatric clinical teams.
View source
Action
Assess paediatric clinicians’ individual needs for genetic-care updates and support any additional training costs.
View source
Action
Establish a regular Regional Clinical Genetics advice point during or after monthly clinics.
View source
Action
Review paediatric communication and care-coordination processes and recommend improvements to Trust governance groups.
View source
Action
Provide Genomics nurse attendance at a paediatric departmental meeting to explain the Regional Genetic Service.
View source
Action
Provide twice-yearly educational contact from the Regional Clinical Genetics Service at established paediatric clinical education meetings.
View source See 3 more actions
×
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
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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 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
Open published response
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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 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
Open published response
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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 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
Open published response
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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 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
Open published response
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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 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
Open published response
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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 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
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations