PFD report

Paul Perrott · Prevention of Future Deaths report

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Issued 2 Dec 2023•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
6

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
11

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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

Concerns raised6

  1. Lack of clarity over the timing of observation chart checks
    Part of recurring concern: Unreliable clinical review of observation charts
  2. Lack of clarity over responsibility for feedback on observation chart problems
    Part of recurring concern: Unreliable patient observation arrangements
  3. Failure to ensure staff awareness of relevant suicide risk history
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.7

  1. Action

    Use redesigned patient handover documents to provide ward staff with rapid access to historical risk information, including when patients move wards.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
  2. Action

    Conduct monthly senior nurse manager audits of observation completion, submit results to governance, provide feedback, and review performance with ward managers.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
  3. Action

    Amend the observation policy to require shift-by-shift completion checks by the nurse in charge and immediate action on omissions.

    Stated by Devon Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Existing multidisciplinary risk review arrangements address dynamic and relevant historical risk factors.

    Stated by Devon Partnership NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 clarity over the timing of observation chart checks

Wider context from the report

“(2) There appeared to be a lack of clarity over who was responsible for checking the observation charts , when they would be checked by staff over the course of a working day and who would regularly feed back to staff if there was a problem in this respect . ”

Is this part of a recurring concern?

Yes — Unreliable clinical review of observation charts.

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 clarity over responsibility for feedback on observation chart problems

Wider context from the report

“(2) There appeared to be a lack of clarity over who was responsible for checking the observation charts , when they would be checked by staff over the course of a working day and who would regularly feed back to staff if there was a problem in this respect . ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

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 ensure staff awareness of relevant suicide risk history

Wider context from the report

“(3) At least one member of staff was unaware that Paul had described himself to staff in May 2020 as looking for an opportunity to take his own life if it arose and that Paul had attempted to take his own life less than 3 months previously in exactly the same way as on 31st July 2020. ”

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

Lack of clarity over responsibility for checking observation charts

Wider context from the report

“(2) There appeared to be a lack of clarity over who was responsible for checking the observation charts , when they would be checked by staff over the course of a working day and who would regularly feed back to staff if there was a problem in this respect . ”

Is this part of a recurring concern?

Yes — Failure to assure reliable patient observations; Unreliable clinical review of observation charts.

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 include historical and contextual risks in risk analysis

Wider context from the report

“(4) Although certain changes to policy and procedures were described to me there still seems to be a focus on risk in the “here and now “which does not include an analysis of historical and contextual risks ”

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 complete observation charts adequately

Wider context from the report

“(1) Paul Perrott’s observations charts were not filled out adequately or at all on the date of his death ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unreliable recording of required observations in care and custody.

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

Use redesigned patient handover documents to provide ward staff with rapid access to historical risk information, including when patients move wards.

Verbatim wording from the response

“The ward handover document has been re-designed. As such, there is a document for each patient which has a photograph of the patient and a section where key historical risk is recorded. This approach makes it possible for a new staff to the ward to have quick access to useful historical risk information during their shifts. This takes into consideration that most patients have lengthy hospital stay with a significant amount of information within the clinical patient record. The handover document is accessible to staff both in hardcopy and electronically. In addition, the new electronic recording platform has been designed in such a way that all clinically relevant risk information are captured on a single domain. This can be updated as new information is received. This is a departure from a system of multiple risk information recording domains.”

Source location

Response from Devon Partnership NHS Trust
Page 3 · response
Published 19 December 2023

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 monthly senior nurse manager audits of observation completion, submit results to governance, provide feedback, and review performance with ward managers.

Verbatim wording from the response

“Policy states that observation audits to check completion of observations are completed monthly by senior nurse managers. This process is in place through the quality review of clinical records and the results of those audits are submitted to the governance manager, feedback to staff and ward governance meetings. The audit performance is then reviewed monthly with ward managers at inpatient governance meetings. Engagement and observation competency checklists are completed for all new staff and these are reviewed and stored by ward managers with the senior nurse manager’s administrator monitoring compliance for wards.”

Source location

Response from Devon Partnership NHS Trust
Page 2 · response
Published 19 December 2023

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

Amend the observation policy to require shift-by-shift completion checks by the nurse in charge and immediate action on omissions.

Verbatim wording from the response

“An amendment to the Trust therapeutic engagement and observation policy has been requested to state that the nurse in charge of each shift is responsible for ensuring completion of observations on a shift by shift basis and taking immediate action where these are not completed. This will go through ratification in January 2024 and has been discussed with the Director and Deputy Director of Nursing.”

Source location

Response from Devon Partnership NHS Trust
Page 2 · response
Published 19 December 2023

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 inpatient wards' shift-by-shift observation-record initials to check that nurses in charge evidence completion.

Verbatim wording from the response

“In addition, the patient observation record has a tick box on each observation sheet where the nurse in charge adds their initials to evidences completion on a shift by shift basis. This has been reviewed on each inpatient ward by the senior nurse manager to check it is being completed by the nurse in charge.”

Source location

Response from Devon Partnership NHS Trust
Page 2 · response
Published 19 December 2023

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

Complete and electronically share HCR-20 violence-risk assessments for every patient at specified admission intervals.

Verbatim wording from the response

“The hospital also employs the use of HCR-20 (Historical Clinical Risk management) tool. This recommended tool is a structured tool to assess the risk of violence and it records historical risk factors in details. The task of completing the HCR-20 document is usually undertaken by the hospital psychology department. The document is presented and shared with members of the Multidisciplinary team after 3 months of admission then every 6 months till a patient is discharged. The HCR-20 assessment is completed for every patient. This is also stored electronically and available to all staff.”

Source location

Response from Devon Partnership NHS Trust
Page 3 · response
Published 19 December 2023

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

Discuss historical and significant risks in daily ward risk meetings and record or share relevant information during ward transfers.

Verbatim wording from the response

“Significant and complex risk (or the potential for those risks) should be discussed in a multi-disciplinary team meeting and reviewed at regular intervals until the risk is felt to have reduced. This is regarded as a good practice (4 steps to safety programme). This is already embedded in the hospital. This model acknowledges the dynamic nature of risk and the significance of relevant historical risk factors. In addition, it allows for flexibility in making adjustments to risk management plans.”

Source location

Response from Devon Partnership NHS Trust
Page 3 · response
Published 19 December 2023

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

Capture clinically relevant risk information in a single electronic recording domain that staff can update as information changes.

Verbatim wording from the response

“The ward handover document has been re-designed. As such, there is a document for each patient which has a photograph of the patient and a section where key historical risk is recorded. This approach makes it possible for a new staff to the ward to have quick access to useful historical risk information during their shifts. This takes into consideration that most patients have lengthy hospital stay with a significant amount of information within the clinical patient record. The handover document is accessible to staff both in hardcopy and electronically. In addition, the new electronic recording platform has been designed in such a way that all clinically relevant risk information are captured on a single domain. This can be updated as new information is received. This is a departure from a system of multiple risk information recording domains.”

Source location

Response from Devon Partnership NHS Trust
Page 3 · response
Published 19 December 2023

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 multidisciplinary risk review arrangements address dynamic and relevant historical risk factors.

Verbatim wording from the response

“Significant and complex risk (or the potential for those risks) should be discussed in a multi-disciplinary team meeting and reviewed at regular intervals until the risk is felt to have reduced. This is regarded as a good practice (4 steps to safety programme). This is already embedded in the hospital. This model acknowledges the dynamic nature of risk and the significance of relevant historical risk factors. In addition, it allows for flexibility in making adjustments to risk management plans.”

Source location

Response from Devon Partnership NHS Trust
Page 3 · response
Published 19 December 2023

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.4

  1. 1

    Discuss significant directorate risk events and share resulting learning with staff through operational meetings and email.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
  2. 2

    Maintain a staff presence in the main ward area capable of identifying risk issues and responding appropriately.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
  3. 3

    Assess and monitor staff competency to undertake engagement and observations, including new staff and delegated personnel.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
  4. 4

    Electronically cascade recorded incident risk information to multidisciplinary team members and hospital managers.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.

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

Discuss significant directorate risk events and share resulting learning with staff through operational meetings and email.

Verbatim wording from the response

“The hospital holds a Directorate operational meeting three times a week. This is attended by ward managers, clinicians, senior nurses, managers and profession Leads. Any significant risk event within the directorate is discussed and learning is shared. The risk information as part of the message from the meeting is cascaded via email to all staff.”

Source location

Response from Devon Partnership NHS Trust
Page 3 · response
Published 19 December 2023

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

Maintain a staff presence in the main ward area capable of identifying risk issues and responding appropriately.

Verbatim wording from the response

“As part of risk management, the hospital added a practice in 2020 that ensures there is also staff member in the main ward area who is able to identify any risk issue and respond appropriately.”

Source location

Response from Devon Partnership NHS Trust
Page 4 · response
Published 19 December 2023

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 and monitor staff competency to undertake engagement and observations, including new staff and delegated personnel.

Verbatim wording from the response

“The therapeutic engagement and observation policy (CO6) appendix 1 clearly states the responsibilities of staff in respect of completing patient observations. In addition, “the nurse in charge is responsible for ensuring that there are adequate staff resources for the implementation of engagement and observations and that all staff required to undertake these are competent to carry out this task”. The policy also states the responsibilities of individual staff as detailed below.”

Source location

Response from Devon Partnership NHS Trust
Page 1 · response
Published 19 December 2023

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

Electronically cascade recorded incident risk information to multidisciplinary team members and hospital managers.

Verbatim wording from the response

“Relevant to risk management, the Trust operates a Risk recording system. There is an already embedded practice where an account of incident is recorded electronically and once uploaded, this is risk information is immediately cascaded electronically to members of the multidisciplinary team and hospital managers. This is received via their NHS emails.”

Source location

Response from Devon Partnership NHS Trust
Page 3 · response
Published 19 December 2023

Open published response
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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