PFD report

Allan Graham Joslin · Prevention of Future Deaths report

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Issued 17 Jul 2019•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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

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 raised2

  1. Lack of adequate mental health facilities or safe rooms for potentially violent patients with complex needs
  2. Failure to facilitate general practitioners’ referrals for formal mental health assessment and treatment
    Part of recurring concern: Unreliable mental health referral pathways
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 mental health facilities or safe rooms for potentially violent patients with complex needs

Wider context from the report

“The Devon Partnership NHS Trust had no adequate mental health care facility or safe room to deal with a patient who presented with complex needs including the need for mental health assessment, and drug and alcohol dependency issues, who was potentially violent. There was no policy in place to facilitate the general practitioners’ referrals and therefore Mr Joslin received no formal assessment or treatment prior to his death. This may have impacted on his ability to receive additional services and assistance with his homeless status. Although this Trust have now put policies and facilities in place to safely treat patients presenting with a history of violence, it was clear from the evidence that this is a concern and difficulty in other Trusts across the country and is not a problem unique to Devon. While working with Devon to find a solution to the problem, NHS England confirmed this was problematic for a number of Trusts regarding provision of secondary care. This is clearly a contravention of Equality legislation for those most vulnerable in society. ”

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 facilitate general practitioners’ referrals for formal mental health assessment and treatment

Wider context from the report

“The Devon Partnership NHS Trust had no adequate mental health care facility or safe room to deal with a patient who presented with complex needs including the need for mental health assessment, and drug and alcohol dependency issues, who was potentially violent. There was no policy in place to facilitate the general practitioners’ referrals and therefore Mr Joslin received no formal assessment or treatment prior to his death. This may have impacted on his ability to receive additional services and assistance with his homeless status. Although this Trust have now put policies and facilities in place to safely treat patients presenting with a history of violence, it was clear from the evidence that this is a concern and difficulty in other Trusts across the country and is not a problem unique to Devon. While working with Devon to find a solution to the problem, NHS England confirmed this was problematic for a number of Trusts regarding provision of secondary care. This is clearly a contravention of Equality legislation for those most vulnerable in society. ”

Is this part of a recurring concern?

Yes — Unreliable mental health referral pathways.

Open source report

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

    Draw the Royal College of Psychiatrists’ risk assessment guide and report to the attention of all NHS mental health trusts through the provider bulletin.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 12 September 2019.
  2. 2

    Send the coroner’s report to the NHS England and NHS Improvement South West Safeguarding Lead.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 12 September 2019.
  3. 3

    Invest up to £30 million over five years to establish 20 trauma-informed specialist mental health services for rough sleepers.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 12 September 2019.
  4. 4

    Implement new integrated primary and community mental health models for adults with severe mental illness, including people with complex needs and coexisting substance use.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 12 September 2019.

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

  1. 1

    Local authorities hold statutory responsibility for commissioning public health services, including drug and alcohol services.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Draw the Royal College of Psychiatrists’ risk assessment guide and report to the attention of all NHS mental health trusts through the provider bulletin.

Verbatim wording from the response

“In 2016, the Royal College of Psychiatrists produced a guide on the ‘Assessment and management of risk to others’ (https://www.rcpsych.ac.uk/docs/default-source/members/supporting-you/managing-and-assessing-risk/assessmentandmanagementrisktoothers.pdf?sfvrsn=a614e4f9 2) for use by psychiatrists and other healthcare professionals. This is based on the College’s report, first produced in 2016 and updated in 2017, ‘Rethinking risk to others in mental health services’ (https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/colleges-reports/college-report-cr201.pdf?sfvrsn=2b83d227 2). Both the guide and report make clear that understanding an individual’s history of violence or risk to others is vitally important in informing the way in which risk is assessed, managed and mitigated overall.”

Source location

2019-0241-Response-by-NHS-England
Page 3 · response
Published 12 September 2019

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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

Send the coroner’s report to the NHS England and NHS Improvement South West Safeguarding Lead.

Verbatim wording from the response

“It is unclear from your report if a copy has been sent to the Trust; it is likely to be useful for the Trust to see your report if they have not already had it. Given the concerns you have raised in your report I can confirm that I have ensured that a copy alongside this reply has been sent to the NHS England and NHS Improvement Safeguarding Lead for the South West region.”

Source location

2019-0241-Response-by-NHS-England
Page 1 · response
Published 12 September 2019

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

Invest up to £30 million over five years to establish 20 trauma-informed specialist mental health services for rough sleepers.

Verbatim wording from the response

“NHS England and NHS Improvement have also committed to investing up to £30 million over the next 5 years to establish 20 new specialist mental health services for rough sleepers. These new services must be trauma informed, (i.e. they must reduce harm and promote healing, especially in individuals who have already experienced trauma¹), and part of an existing approach to supporting rough sleepers, which includes existing drug and alcohol support.² It is important that all Mental Health Trusts, regardless of whether they receive this funding, work closely with local authorities and partners from the Voluntary, Community and Social Enterprise (VCSE) sector to better support rough sleepers.”

Source location

2019-0241-Response-by-NHS-England
Page 2 · response
Published 12 September 2019

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 new integrated primary and community mental health models for adults with severe mental illness, including people with complex needs and coexisting substance use.

Verbatim wording from the response

“In recognition of the above, including the specific concerns you raise regarding the provision of secondary care to those most vulnerable in society, I can confirm we are taking specific steps to improve access to, and quality of, support for people with co-existing SMI and substance use. The NHS Long Term Plan, published earlier this year, details how new and integrated models of primary and community health services will transform the delivery of mental health care for adults and older adults with SMI, including people with complex needs and co-existing substance use. As the NHS Mental Health Implementation Plan 2019/20 – 2023/24 sets out, this new community-based offer is backed by significant investment over the next five years.”

Source location

2019-0241-Response-by-NHS-England
Page 2 · response
Published 12 September 2019

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

Local authorities hold statutory responsibility for commissioning public health services, including drug and alcohol services.

Verbatim wording from the response

“The Health and Social Care Act 2012 transferred statutory responsibility for the commissioning of public health services, including drug and alcohol services, to local authorities. NHS England and NHS Improvement do recognise it is a very important issue, with significant implications for”

Source location

2019-0241-Response-by-NHS-England
Page 1 · response
Published 12 September 2019

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