PFD report

Louise Turner · Prevention of Future Deaths report

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Issued 7 Sep 2016•Exeter and Greater 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
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
4

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. Inadequate staff training on responsibility for patient contact
    Part of recurring concern: Inadequate staff training for managing complex care needs
  2. Failure to ensure staff-led contact for patients with severe mental health conditions
  3. Lack of adequate post-discharge mental health care and contact
    Part of recurring concern: Failure to provide timely and adequate follow-up after dischargePart of recurring concern: Unreliable interim mental health support during care transitions
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.2

  1. Action

    Lead an option appraisal with Peninsula commissioners and providers to identify the need for a Devon psychiatric intensive care unit.

    Stated by NHS Devon Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 7 September 2016.
  2. Action

    Review and agree a proposal for a 10-bed psychiatric intensive care unit on the Wonford Hospital site.

    Stated by NHS Devon Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 7 September 2016.

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

  1. Position

    Devon Partnership NHS Trust should develop the plan for designing, constructing and operating the local psychiatric intensive care unit.

    Stated by NHS Devon Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Inadequate staff training on responsibility for patient contact

Wider context from the report

“(3) There was a suggestion at Inquest that the patients themselves were expected to be in charge of making contact. In cases of severe mental health, this does not appear to be appropriate or realistic, and the Devon Partnership Trust should reconsider this and/or the training of their staff who hold this belief. ”

Is this part of a recurring concern?

Yes — Inadequate staff training for managing complex care needs.

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-led contact for patients with severe mental health conditions

Wider context from the report

“(3) There was a suggestion at Inquest that the patients themselves were expected to be in charge of making contact. In cases of severe mental health, this does not appear to be appropriate or realistic, and the Devon Partnership Trust should reconsider this and/or the training of their staff who hold this belief. ”

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 adequate post-discharge mental health care and contact

Wider context from the report

“(1) The Devon Partnership trust had no adequate mental health care for Louise after she was discharged. There was inadequate contact and no explanation at Inquest as to why this had not taken place. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate follow-up after discharge; Unreliable interim mental health support during care transitions.

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 of effective and robust duty system arrangements

Wider context from the report

“(2) The duty system arrangements and buddying system referred to at Inquest were not effective or robust and need to be reconsidered in the light of the outcome of this case. ”

Is this part of a recurring concern?

Yes — Unreliable duty system arrangements for safe clinical coverage.

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 of an effective and robust buddying system

Wider context from the report

“(2) The duty system arrangements and buddying system referred to at Inquest were not effective or robust and need to be reconsidered in the light of the outcome of this case. ”

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

Unavailability of female psychiatric intensive care beds in Devon

Wider context from the report

“(4) There are no female intensive care beds for psychiatric patients in Devon. This does not match the desired parity of mental health care with physical health care. Devon Partnership Trust needs to consider future planning and provision to ensure the needs of patients can be met. ”

Is this part of a recurring concern?

Yes — Insufficient psychiatric inpatient bed capacity.

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

Lead an option appraisal with Peninsula commissioners and providers to identify the need for a Devon psychiatric intensive care unit.

Verbatim wording from the response

“Following the publication of the Mental Health Crisis Care Concordat and the Care Quality Commission (CQC) inspection report into Devon Partnership NHS Trust in February 2014, it was identified that the lack of a Psychiatric Intensive Care Unit (PICU) in Devon was a significant deficit to the mental health acute care system. This was further magnified by the publication of the Crisp Report (Crisp, N., Smith, G. and Nicholson, K. (Eds.) Old Problems, New Solutions – Improving Acute Psychiatric Care) which identified serious issues with the use of out of area placements for people experiencing acute mental ill health.”

Source location

2016-0322-Response-by-Northern-Eastern-and-Western-Devon-Clinical-Commissioning-Group
Page 2 · response
Published 7 September 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 and agree a proposal for a 10-bed psychiatric intensive care unit on the Wonford Hospital site.

Verbatim wording from the response

“The CCG led an option appraisal including all the Peninsula commissioners and providers, where it was identified that a PICU was required in Devon. This proposal was considered by the CCG and it was concluded that the revenue funding to support the operation of a PICU was available within the Devon Partnership NHS Trust contract and that they should develop a plan for the design, construction and operation of a PICU within Devon to ensure provision across Devon, Plymouth and Torbay. A proposal to build a local PICU facility was reviewed and agreed by the CCG Executive Committee on 20 July 2016 with the Governing Body confirming their support for implementation for a local, 10 bedded PICU on the Wonford Hospital site, adjacent to the Cedars Mental Health Acute Unit by April 2018.”

Source location

2016-0322-Response-by-Northern-Eastern-and-Western-Devon-Clinical-Commissioning-Group
Page 2 · response
Published 7 September 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

Devon Partnership NHS Trust should develop the plan for designing, constructing and operating the local psychiatric intensive care unit.

Verbatim wording from the response

“The CCG led an option appraisal including all the Peninsula commissioners and providers, where it was identified that a PICU was required in Devon. This proposal was considered by the CCG and it was concluded that the revenue funding to support the operation of a PICU was available within the Devon Partnership NHS Trust contract and that they should develop a plan for the design, construction and operation of a PICU within Devon to ensure provision across Devon, Plymouth and Torbay. A proposal to build a local PICU facility was reviewed and agreed by the CCG Executive Committee on 20 July 2016 with the Governing Body confirming their support for implementation for a local, 10 bedded PICU on the Wonford Hospital site, adjacent to the Cedars Mental Health Acute Unit by April 2018.”

Source location

2016-0322-Response-by-Northern-Eastern-and-Western-Devon-Clinical-Commissioning-Group
Page 2 · response
Published 7 September 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.2

  1. 1

    Record serious-incident actions in CCG safety systems and follow up closure evidence through routine meetings with the provider’s serious-incident team.

    Stated by NHS Devon Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 7 September 2016.
  2. 2

    Continue collaborative, multi-agency improvement measures under a local governance framework to support safe responses to mental health crises.

    Stated by NHS Devon Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 7 September 2016.

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

Record serious-incident actions in CCG safety systems and follow up closure evidence through routine meetings with the provider’s serious-incident team.

Verbatim wording from the response

“With regard to serious incident investigations, specific actions are identified from the report recommendations in order to mitigate against a re-occurrence. The CCG requires assurance that these actions are progressed and implemented and that learning is embedded within provider organisations.”

Source location

2016-0322-Response-by-Northern-Eastern-and-Western-Devon-Clinical-Commissioning-Group
Page 2 · response
Published 7 September 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

Continue collaborative, multi-agency improvement measures under a local governance framework to support safe responses to mental health crises.

Verbatim wording from the response

“The CCG is committed to a jointly shared program of actions aligned to the Mental Health Crisis Care Concordat, along with other partner and stakeholder organisation including NHS providers and Devon and Cornwall Police. Through strong collaboration and a robust local governance framework, a series of improvement measures are”

Source location

2016-0322-Response-by-Northern-Eastern-and-Western-Devon-Clinical-Commissioning-Group
Page 2 · response
Published 7 September 2016

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