David John Ireland · Prevention of Future Deaths report

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Issued 27 Feb 2018•Exeter and Greater Devon

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

Described in responses

Recipients and published responses

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 raised1

  1. Failure to advise about emergency department presentation when mental health crisis concerns continue
    Part of recurring concern: Unreliable crisis team care provision

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. Devon Partnership NHS Trust

    Review relevant answer-machine messages and add references to all appropriate sources of further support.

  2. Devon Partnership NHS Trust

    Include the concern in the next Trust-wide Safety Briefing.

  3. Devon Partnership NHS Trust

    Raise the concern with relevant teams through local learning-from-experience groups and equivalent forums.

  4. Devon Partnership NHS Trust

    Share the coroner’s findings with the involved service and across the Trust.

  5. Devon Partnership NHS Trust

    Include advice about giving options for further support in local induction for temporary workers in the relevant teams.

  6. Devon Partnership NHS Trust

    Complete a Root Cause Analysis investigation and share its report at the inquest.

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 advise about emergency department presentation when mental health crisis concerns continue

Wider context from the report

“(1) Contact was made by Mr Ireland’s friend on the day of his death with the crisis team. Mr Ireland also spoke with them during the same telephone contact call. No advice was given that Mr Ireland could present at the emergency department should concerns continue about his mental health crisis. Had such advice been given it may have impacted on the course of events and facilitated an urgent mental health assessment. This opportunity was lost as Mr Ireland was not able to make any such decision and his friend was unaware that this was an option available with sudden onset mental health symptoms. ”

Is this part of a recurring concern?

Yes — Unreliable crisis team care provision.

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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

Review relevant answer-machine messages and add references to all appropriate sources of further support.

Verbatim wording from the response

“We have asked the relevant teams to review any answer machine messages they use and include appropriate reference to all sources of further support.”

Source location

2018-0057-Response-by-Devon-Partnership-NHS-Trust
Page 1 · response
Published 8 June 2018

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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

Include the concern in the next Trust-wide Safety Briefing.

Verbatim wording from the response

“We will be including specific reference to this concern in our next Trust wide ‘Safety Briefing’ which is made available to all staff, we have also asked for this concern to be raised with the relevant teams through their local learning from experience groups and equivalent forums. We would be happy to provide a copy of the Safety Briefing when it is available.”

Source location

2018-0057-Response-by-Devon-Partnership-NHS-Trust
Page 1 · response
Published 8 June 2018

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

Raise the concern with relevant teams through local learning-from-experience groups and equivalent forums.

Verbatim wording from the response

“We will be including specific reference to this concern in our next Trust wide ‘Safety Briefing’ which is made available to all staff, we have also asked for this concern to be raised with the relevant teams through their local learning from experience groups and equivalent forums. We would be happy to provide a copy of the Safety Briefing when it is available.”

Source location

2018-0057-Response-by-Devon-Partnership-NHS-Trust
Page 1 · response
Published 8 June 2018

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

Share the coroner’s findings with the involved service and across the Trust.

Verbatim wording from the response

“Thank you for your letter of 27 February 2018 which we received on the 5 March 2018 following the inquest into the death of David Ireland. As an organisation we are committed to learning from these tragic events and have since receiving your report and recommendations taken the opportunity to share your findings with the service involved as well as across the wider trust.”

Source location

2018-0057-Response-by-Devon-Partnership-NHS-Trust
Page 1 · response
Published 8 June 2018

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

Include advice about giving options for further support in local induction for temporary workers in the relevant teams.

Verbatim wording from the response

“We will be including the need to give this advice in our local induction for temporary workers (agency staff) within these teams.”

Source location

2018-0057-Response-by-Devon-Partnership-NHS-Trust
Page 1 · response
Published 8 June 2018

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 a Root Cause Analysis investigation and share its report at the inquest.

Verbatim wording from the response

“The Trust has undertaken a Root Cause Analysis Investigation following the death of David; the report was shared at the inquest.”

Source location

2018-0057-Response-by-Devon-Partnership-NHS-Trust
Page 1 · response
Published 8 June 2018

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