PFD report

Diane Knight · Prevention of Future Deaths report

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Issued 22 Oct 2015•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
5

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. Failure of door privacy arrangements to prevent concealment of patient self-harm attempts
    Part of recurring concern: Failure to maintain adequate visibility for patient monitoring
  2. Failure of door privacy arrangements to maintain staff visibility of patients
    Part of recurring concern: Failure to maintain adequate visibility for patient monitoring
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.4

  1. Action

    Discontinue covering bedroom observation windows with towels or similar items across inpatient areas.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 22 October 2015.
  2. Action

    Publish and distribute a trust-wide safety briefing requiring immediate action to prevent bedroom-window coverings from obstructing patient observation.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 22 October 2015.
  3. Action

    Issue a further local alert to inpatient units and obtain formal ward responses confirming review and appropriate action.

    Stated by Devon Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 22 October 2015.

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 door privacy arrangements to prevent concealment of patient self-harm attempts

Wider context from the report

“(1) The continued practice of putting a towel over the door could hide an attempt by a patient to harm themselves or end their life such as here with a belt end being trapped by the door against the door jamb. (2) The continuation of this practice may prevent staff being properly able to monitor the patients on the Unit, therefore this practice should be reviewed. (3) An alternative method for preserving patient privacy should be considered that would not allow a patient to conceal an attempt to cause themselves harm. ”

Is this part of a recurring concern?

Yes — Failure to maintain adequate visibility for patient monitoring.

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 door privacy arrangements to maintain staff visibility of patients

Wider context from the report

“(1) The continued practice of putting a towel over the door could hide an attempt by a patient to harm themselves or end their life such as here with a belt end being trapped by the door against the door jamb. (2) The continuation of this practice may prevent staff being properly able to monitor the patients on the Unit, therefore this practice should be reviewed. (3) An alternative method for preserving patient privacy should be considered that would not allow a patient to conceal an attempt to cause themselves harm. ”

Is this part of a recurring concern?

Yes — Failure to maintain adequate visibility for patient monitoring.

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

Discontinue covering bedroom observation windows with towels or similar items across inpatient areas.

Verbatim wording from the response

“(1) The practice of patients obscuring/covering the glass windows in their bedroom doors will be discontinued across all inpatient areas within Devon Partnership NHS Trust. A patient safety alert will be issued highlighting the risks and the actions required to be taken to eradicate this risk.”

Source location

Diane-Knight-Response
Page 1 · response
Published 22 October 2015

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

Publish and distribute a trust-wide safety briefing requiring immediate action to prevent bedroom-window coverings from obstructing patient observation.

Verbatim wording from the response

“A trust wide safety briefing has been produced and was published on our Trust intranet, this is accessible to all staff and is one of the ways in which we publish and share learning across our services. This briefing was also included in our ‘on-line news’ which is sent out by email to all staff.”

Source location

Diane-Knight-Response
Page 2 · response
Published 22 October 2015

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

Issue a further local alert to inpatient units and obtain formal ward responses confirming review and appropriate action.

Verbatim wording from the response

“We plan to issue a further local alert to all inpatient units which will be sent using our alerts process; this requires a formal response from each ward confirming that the alert has been reviewed and appropriate action taken. This is going to be sent once the RCA report has been agreed so any further actions from the commissioner’s review can be included. This is due to be completed by the end of January 2016 (following agreement of the report by the commissioner).”

Source location

Diane-Knight-Response
Page 2 · response
Published 22 October 2015

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

Develop and complete a Respect and Dignity Audit requiring teams to consider safe ways to maintain privacy.

Verbatim wording from the response

“We are in the process of developing our Respect and Dignity Audit; we will be including a specific requirement for teams to consider how they maintain privacy in these types of situation and what more can be done to keep patients safe whilst maintaining their privacy. This audit will then inform any wider actions needed. The audit is due to be completed by the end of January 2016.”

Source location

Diane-Knight-Response
Page 2 · response
Published 22 October 2015

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

    Progress the Root Cause Analysis report through commissioner review and approval.

    Stated by Devon Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 October 2015.

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

Progress the Root Cause Analysis report through commissioner review and approval.

Verbatim wording from the response

“The Trust has undertaken a Root Cause Analysis Investigation following the death of Diane Knight; the report is currently in draft form and has been submitted to our commissioner for review and approval. A copy of the draft report has been included for information, however this may be subject to further changes once the commissioner has reviewed the report. The draft report has not yet been shared with the family. We will be sharing the report with the family once the commissioner has approved it and we would be happy to forward a copy to you at the same time.”

Source location

Diane-Knight-Response
Page 1 · response
Published 22 October 2015

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