PFD report

Michael John Valentine · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 2 Feb 2016•Plymouth, Torbay and South Devon

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
6

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Failure to re-refer patients to the Mental Health Team when clinically appropriate
    Part of recurring concern: Unreliable mental health referral pathways
  2. Lack of a defined response process for rejected mental health assessment applications
  3. Failure to promptly identify and bring rejected mental health assessment requests to clinical attention
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Action

    Meet with secondary-care psychiatry colleagues to discuss referral rejection and complete a Significant Event analysis of the death.

    Stated by Knowle House SurgeryStated completedThe respondent said that this action was complete when they made their response on 2 February 2016.
  2. Action

    Write jointly to the head of DRSS to request review of procedures for communicating rejected urgent mental-health referrals to requesting GPs.

    Stated by Knowle House SurgeryStated plannedThe respondent said that this action was planned when they made their response on 2 February 2016.
  3. Action

    Establish robust procedures for safely reviewing post and electronic communications, supported by post audits and re-audit.

    Stated by Knowle House SurgeryStated completedThe respondent said that this action was complete when they made their response on 2 February 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The hunger strike was considered likely to result in a slow suicide, so the urgent referral was not considered to require an immediate response.

    Stated by Knowle House SurgeryDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to re-refer patients to the Mental Health Team when clinically appropriate

Wider context from the report

“(1) A fax rejecting the request for a mental health assessment was sent back to the Surgery. This was classed as routine and was not brought to the attention of ████████. It was left in a tray for dealing (filing) but, unfortunately, due to staff absence, this did not come to light until after the death of Mr Valentine. (2) After the telephone consultation on 10 September, ████████ agreed that it would have been appropriate to refer Mr Valentine to the Mental Health Team for a second time given his disclosure that he had not eaten for 25 days. (3) ████████ told the Court that there had been a significant events meeting which had looked at the administrative shortcomings in the Surgery. There had been no discussion, however, of her decision not to re-refer following the 10 September telephone contact. Similarly, there has been no discussion of what to do where an application for a mental health assessment has been rejected. ”

Is this part of a recurring concern?

Yes — Unreliable mental health referral pathways.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of a defined response process for rejected mental health assessment applications

Wider context from the report

“(1) A fax rejecting the request for a mental health assessment was sent back to the Surgery. This was classed as routine and was not brought to the attention of ████████. It was left in a tray for dealing (filing) but, unfortunately, due to staff absence, this did not come to light until after the death of Mr Valentine. (2) After the telephone consultation on 10 September, ████████ agreed that it would have been appropriate to refer Mr Valentine to the Mental Health Team for a second time given his disclosure that he had not eaten for 25 days. (3) ████████ told the Court that there had been a significant events meeting which had looked at the administrative shortcomings in the Surgery. There had been no discussion, however, of her decision not to re-refer following the 10 September telephone contact. Similarly, there has been no discussion of what to do where an application for a mental health assessment has been rejected. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to promptly identify and bring rejected mental health assessment requests to clinical attention

Wider context from the report

“(1) A fax rejecting the request for a mental health assessment was sent back to the Surgery. This was classed as routine and was not brought to the attention of ████████. It was left in a tray for dealing (filing) but, unfortunately, due to staff absence, this did not come to light until after the death of Mr Valentine. (2) After the telephone consultation on 10 September, ████████ agreed that it would have been appropriate to refer Mr Valentine to the Mental Health Team for a second time given his disclosure that he had not eaten for 25 days. (3) ████████ told the Court that there had been a significant events meeting which had looked at the administrative shortcomings in the Surgery. There had been no discussion, however, of her decision not to re-refer following the 10 September telephone contact. Similarly, there has been no discussion of what to do where an application for a mental health assessment has been rejected. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to review decisions not to re-refer patients to the Mental Health Team

Wider context from the report

“(1) A fax rejecting the request for a mental health assessment was sent back to the Surgery. This was classed as routine and was not brought to the attention of ████████. It was left in a tray for dealing (filing) but, unfortunately, due to staff absence, this did not come to light until after the death of Mr Valentine. (2) After the telephone consultation on 10 September, ████████ agreed that it would have been appropriate to refer Mr Valentine to the Mental Health Team for a second time given his disclosure that he had not eaten for 25 days. (3) ████████ told the Court that there had been a significant events meeting which had looked at the administrative shortcomings in the Surgery. There had been no discussion, however, of her decision not to re-refer following the 10 September telephone contact. Similarly, there has been no discussion of what to do where an application for a mental health assessment has been rejected. ”

Is this part of a recurring concern?

Yes — Unreliable mental health referral pathways.

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

Meet with secondary-care psychiatry colleagues to discuss referral rejection and complete a Significant Event analysis of the death.

Verbatim wording from the response

“We met with our Secondary Care Psychiatry colleagues on 18th March 2016 and discussed the rejection process as well as carrying out a Significant Event analysis on Mr Valentine’s death.”

Source location

Michael-Valentine-Response
Page 1 · response
Published 2 February 2016

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

Write jointly to the head of DRSS to request review of procedures for communicating rejected urgent mental-health referrals to requesting GPs.

Verbatim wording from the response

“It was discussed between the parties that any urgent referrals rejected should be phoned through to the surgery and this should be confirmed by DRSS as Mental Health Services triage referrals on their behalf.”

Source location

Michael-Valentine-Response
Page 2 · response
Published 2 February 2016

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 robust procedures for safely reviewing post and electronic communications, supported by post audits and re-audit.

Verbatim wording from the response

“An audit of post was taken on 23/2/16. 235 pieces of correspondence were referred on this day. 216 were distributed to the GPs working that day. 1 GP does not routinely work that day and 19 pieces of correspondence were reviewed by the Duty Doctor for urgency and 18 pieces of correspondence were deemed safe to leave for the doctors return one day later.”

Source location

Michael-Valentine-Response
Page 1 · response
Published 2 February 2016

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 the process for urgent referrals.

Verbatim wording from the response

“I am writing in response to your letter sent to our Medical Director. In order to progress this we have had a meeting with Senior Management of Livewell South West and myself as Clinical Director of Adult Mental Health and have reviewed the case. We have reviewed the process of urgent referrals. We note that Knowle House Surgery considered this as part of their Significant Event Process and we met with the practice on Friday 18th March. We understand that the practice will forward a record of the meeting to you.”

Source location

Michael-Valentine-Response2
Page 1 · response
Published 2 February 2016

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

Contact referrers directly to confirm assessment outcomes whenever staff reject urgent referrals.

Verbatim wording from the response

“1. In future any staff that reject an urgent referral will be contacting the referrer direct to confirm the outcome of their assessment of the referral.”

Source location

Michael-Valentine-Response2
Page 1 · response
Published 2 February 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 hunger strike was considered likely to result in a slow suicide, so the urgent referral was not considered to require an immediate response.

Verbatim wording from the response

“After discussion it was confirmed that the referral requested was a Mental Capacity Assessment and not a Mental Health Act Assessment. Although the referral was put through as urgent the fact that he was on hunger strike meant that his suicide was likely to be slow and the request for a physical health examination was reasonable.”

Source location

Michael-Valentine-Response
Page 2 · response
Published 2 February 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

Existing procedures for reviewing post and electronic communication were considered robust enough to keep patients safe.

Verbatim wording from the response

“On balance we are happy that we now have robust procedures for reviewing post and electronic communication within the Practice to keep our patients safe.”

Source location

Michael-Valentine-Response
Page 1 · response
Published 2 February 2016

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Seek Local Medical Committee advice on sharing learning across primary and secondary care.

    Stated by Livewell SouthwestStated plannedThe respondent said that this action was planned when they made their response on 2 February 2016.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The referral requested a mental health assessment, not a Mental Health Act assessment, which follows a different process.

    Stated by Livewell SouthwestDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Seek Local Medical Committee advice on sharing learning across primary and secondary care.

Verbatim wording from the response

“3. We will be seeking advice from the Local Medical Committee to ask how learning can be shared throughout the Primary Care area and Secondary Care arena.”

Source location

Michael-Valentine-Response2
Page 1 · response
Published 2 February 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 referral requested a mental health assessment, not a Mental Health Act assessment, which follows a different process.

Verbatim wording from the response

“On a matter of accuracy, the request for an assessment from the North Community Mental Health Team was a request for a Mental Health assessment, not a Mental Health Act assessment, which would be a different process.”

Source location

Michael-Valentine-Response2
Page 1 · response
Published 2 February 2016

Open published response
Back to top

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026