Robert Lloyd · Prevention of Future Deaths report

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Issued 29 Nov 2016•Cornwall and Isles of Scilly

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
2

Raised in this report

Recipients
4

Named on the report

Responses found
2

Of 4 recipients

Stated actions
17

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 raised2

  1. Reduced access to face-to-face alcohol reduction workers and Alcoholics Anonymous support on the Mainland
  2. Lack of accessible face-to-face alcohol support on the Isles of Scilly

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.17

  1. Isles of Scilly Health Centre

    Ensure problem alcohol use is included on the Community Safety Partnership agenda.

  2. Isles of Scilly Health Centre

    Introduce a new Island addiction worker visiting every two weeks and host sessions at the surgery with access to multidisciplinary team meetings.

  3. Isles of Scilly Health Centre

    Train the practice’s two pharmacists to identify people at risk of harm from excess alcohol consumption.

  4. Isles of Scilly Health Centre

    Meet with Cornwall Council’s Drug and Alcohol Action Team to discuss future services and joint improvement work.

  5. Isles of Scilly Health Centre

    Audit patients recorded in General Practice notes as exceeding recommended alcohol intake limits.

  6. Drug & Alcohol Action Team Cornwall and Isles of Scilly

    Complete the Isles of Scilly needs assessment and commissioning intentions for 2017–18.

  7. Drug & Alcohol Action Team Cornwall and Isles of Scilly

    Use multi-agency professional meetings to identify people for assertive treatment engagement and support.

  8. Drug & Alcohol Action Team Cornwall and Isles of Scilly

    Review the situation and improvement plan through quarterly contract-review meetings with Addaction, the Isles of Scilly Council and stakeholders.

  9. Drug & Alcohol Action Team Cornwall and Isles of Scilly

    Implement a hospital-discharge protocol linking mainland admissions to the islands’ Addiction Recovery Co-ordinator for community treatment referrals.

  10. Drug & Alcohol Action Team Cornwall and Isles of Scilly

    Offer refresher training for island-serving personnel on alcohol screening and awareness in April 2017.

  11. Drug & Alcohol Action Team Cornwall and Isles of Scilly

    Train island-serving GPs to provide the full spectrum of primary-care alcohol and drug treatments.

  12. Drug & Alcohol Action Team Cornwall and Isles of Scilly

    Continue investing in DAAT staff support for the islands, including representation on strategic groups.

  13. Drug & Alcohol Action Team Cornwall and Isles of Scilly

    Train pharmacy staff to screen patients for health risks associated with drinking.

  14. Drug & Alcohol Action Team Cornwall and Isles of Scilly

    Provide a proactive Adults Recovery Co-ordinator with fortnightly island visits and support for affected families and friends.

  15. Drug & Alcohol Action Team Cornwall and Isles of Scilly

    Provide sickness and annual-leave cover for the Adults Recovery Co-ordinator.

  16. Drug & Alcohol Action Team Cornwall and Isles of Scilly

    Deliver regular AA and NA meetings on the islands.

  17. Drug & Alcohol Action Team Cornwall and Isles of Scilly

    Commission at least fortnightly island visits delivering face-to-face recovery support, drop-ins, resources, detox access, prescribing, volunteer support and group therapy.

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

Reduced access to face-to-face alcohol reduction workers and Alcoholics Anonymous support on the Mainland

Wider context from the report

“At the inquest evidence was read from the GP and Addaction as to Mr Lloyd’s abuse of alcohol and the difficulty in providing supportive treatment for alcohol abusers on the Isles of Scilly. It was acknowledged that due to the island's location and with limited air and boat services after the termination of the helicopter service some years ago, the support was limited. This has meant that the service users on the Islands have had limited face to face support and had to rely of video link support due to the inability of alcohol support professionals to travel to the Islands in bad weather. This had led to a difficulty in engaging with this group of users. Mr Lloyd’s mother, at inquest explained how the reduction in service (on the termination of the helicopter service) had affected her son and made it more difficult for him to control his drinking habit especially on a small island with a strong alcohol drinking culture. In the past he had access to face to face alcohol reduction workers and he was able to attend (for a small travel fee) the Alcoholics Anonymous group on the Main Land. ”

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 accessible face-to-face alcohol support on the Isles of Scilly

Wider context from the report

“At the inquest evidence was read from the GP and Addaction as to Mr Lloyd’s abuse of alcohol and the difficulty in providing supportive treatment for alcohol abusers on the Isles of Scilly. It was acknowledged that due to the island's location and with limited air and boat services after the termination of the helicopter service some years ago, the support was limited. This has meant that the service users on the Islands have had limited face to face support and had to rely of video link support due to the inability of alcohol support professionals to travel to the Islands in bad weather. This had led to a difficulty in engaging with this group of users. Mr Lloyd’s mother, at inquest explained how the reduction in service (on the termination of the helicopter service) had affected her son and made it more difficult for him to control his drinking habit especially on a small island with a strong alcohol drinking culture. In the past he had access to face to face alcohol reduction workers and he was able to attend (for a small travel fee) the Alcoholics Anonymous group on the Main Land. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Ensure problem alcohol use is included on the Community Safety Partnership agenda.

Verbatim wording from the response

“Both Angela and I sit on the Community Safety Partnership, so we will ensure that the subject of problem alcohol use is on the agenda. The main focus of the CSP this year is around domestic abuse, so enhanced alcohol services will sit well alongside this as a focus.”

Source location

2016-0425-Response-by-The-Health-Centre
Page 1 · response
Published 19 February 2017

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

Introduce a new Island addiction worker visiting every two weeks and host sessions at the surgery with access to multidisciplinary team meetings.

Verbatim wording from the response

“I met with ████████ of the Drug and Alcohol Action Team of Cornwall Council, on the 12th January to discuss future services and how we can work together to ensure services improve. We will shortly be having a new Addiction worker on the Islands who will visit every 2 weeks. This will be a vast improvement on the previous set-up, where often contact was by telephone or Skype. We will host his sessions here at the surgery to ensure that we improve multi-agency working. He will also be able to feed into our multi-disciplinary team meetings for clients as required.”

Source location

2016-0425-Response-by-The-Health-Centre
Page 1 · response
Published 19 February 2017

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

Train the practice’s two pharmacists to identify people at risk of harm from excess alcohol consumption.

Verbatim wording from the response

“In addition to this, training for our two pharmacists has been undertaken, to try and identify those who are at risk of harm from excess alcohol consumption and we are carrying out an audit of those who are recorded on our General Practice notes as having an alcohol intake of greater than the recommended limits. This will assist us in targeting advice to those who most need it, with the aim of increasing referrals to Addiction.”

Source location

2016-0425-Response-by-The-Health-Centre
Page 1 · response
Published 19 February 2017

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

Meet with Cornwall Council’s Drug and Alcohol Action Team to discuss future services and joint improvement work.

Verbatim wording from the response

“I met with ████████ of the Drug and Alcohol Action Team of Cornwall Council, on the 12th January to discuss future services and how we can work together to ensure services improve. We will shortly be having a new Addiction worker on the Islands who will visit every 2 weeks. This will be a vast improvement on the previous set-up, where often contact was by telephone or Skype. We will host his sessions here at the surgery to ensure that we improve multi-agency working. He will also be able to feed into our multi-disciplinary team meetings for clients as required.”

Source location

2016-0425-Response-by-The-Health-Centre
Page 1 · response
Published 19 February 2017

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

Audit patients recorded in General Practice notes as exceeding recommended alcohol intake limits.

Verbatim wording from the response

“In addition to this, training for our two pharmacists has been undertaken, to try and identify those who are at risk of harm from excess alcohol consumption and we are carrying out an audit of those who are recorded on our General Practice notes as having an alcohol intake of greater than the recommended limits. This will assist us in targeting advice to those who most need it, with the aim of increasing referrals to Addiction.”

Source location

2016-0425-Response-by-The-Health-Centre
Page 1 · response
Published 19 February 2017

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 the Isles of Scilly needs assessment and commissioning intentions for 2017–18.

Verbatim wording from the response

“CIOS DAAT committed to undertaking a needs assessment with IOS during 2016-17. A member of our team has been working with the Council for the Isles of Scilly, health partners, the police and Addiction to identify ways in which we could all improve provision. Initial work has included interviews with key health and social care personnel, staff working in housing, licensing, school and police. The public survey conducted in conjunction with IOS Healthwatch received more than 30 responses. Feedback and anecdote estimate high prevalence of problematic drinking on IOS with a degree of disruption to the community including anti-social behaviour and visible health burdens (see attached report update October 2016).”

Source location

2016-0425-Response-by-Drug-Alcohol-Action-Team
Page 1 · response
Published 19 February 2017

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

Use multi-agency professional meetings to identify people for assertive treatment engagement and support.

Verbatim wording from the response

“4. Multi-agency professionals meetings will identify individuals to assertively engage in treatment and support that engagement”

Source location

2016-0425-Response-by-Drug-Alcohol-Action-Team
Page 2 · response
Published 19 February 2017

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 the situation and improvement plan through quarterly contract-review meetings with Addaction, the Isles of Scilly Council and stakeholders.

Verbatim wording from the response

“I believe that these steps will address the issues highlighted within your report, but that there is still more work to do to raise awareness and improve services available to islanders, thereby preventing future deaths. We commit to keeping the situation and improvement plan under regular review through quarterly Contract Review meetings with Addaction and with the Isles of Scilly Council and stakeholders.”

Source location

2016-0425-Response-by-Drug-Alcohol-Action-Team
Page 3 · response
Published 19 February 2017

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 a hospital-discharge protocol linking mainland admissions to the islands’ Addiction Recovery Co-ordinator for community treatment referrals.

Verbatim wording from the response

“3. Where there has been a hospital admission on the mainland, RCHT Alcohol Liaison Team have agreed a joint protocol to contact the designated Addiction Recovery Coordinator for the islands to facilitate a referral for anyone admitted who is not engaged in community treatment, into treatment, once discharged.”

Source location

2016-0425-Response-by-Drug-Alcohol-Action-Team
Page 2 · response
Published 19 February 2017

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

Offer refresher training for island-serving personnel on alcohol screening and awareness in April 2017.

Verbatim wording from the response

“7. A full package of training for all personnel serving the islands in screening for alcohol use and awareness will be offered again in April 2017.”

Source location

2016-0425-Response-by-Drug-Alcohol-Action-Team
Page 3 · response
Published 19 February 2017

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

Train island-serving GPs to provide the full spectrum of primary-care alcohol and drug treatments.

Verbatim wording from the response

“5. The GPs serving the IOS are trained to offer the full spectrum of primary care alcohol and drug treatments.”

Source location

2016-0425-Response-by-Drug-Alcohol-Action-Team
Page 3 · response
Published 19 February 2017

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 investing in DAAT staff support for the islands, including representation on strategic groups.

Verbatim wording from the response

“10. We will make a continuing investment in DAAT staff support for the islands, including representation on strategic groups such as the Community Safety Partnership.”

Source location

2016-0425-Response-by-Drug-Alcohol-Action-Team
Page 3 · response
Published 19 February 2017

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

Train pharmacy staff to screen patients for health risks associated with drinking.

Verbatim wording from the response

“6. Pharmacy staff are trained to screen patients to identify risks to health through drinking.”

Source location

2016-0425-Response-by-Drug-Alcohol-Action-Team
Page 3 · response
Published 19 February 2017

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

Provide a proactive Adults Recovery Co-ordinator with fortnightly island visits and support for affected families and friends.

Verbatim wording from the response

“A new Adults Recovery Co-ordinator has been appointed, with a brief to be more proactive. He has commenced fortnightly visits to the islands. He will also have back/replacement cover for sickness and annual leave, will establish a regular AA meeting on the islands, to replace the need for islanders having to travel to the mainland for this, and provide support for affected others (families and friends).”

Source location

2016-0425-Response-by-Drug-Alcohol-Action-Team
Page 2 · response
Published 19 February 2017

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

Provide sickness and annual-leave cover for the Adults Recovery Co-ordinator.

Verbatim wording from the response

“A new Adults Recovery Co-ordinator has been appointed, with a brief to be more proactive. He has commenced fortnightly visits to the islands. He will also have back/replacement cover for sickness and annual leave, will establish a regular AA meeting on the islands, to replace the need for islanders having to travel to the mainland for this, and provide support for affected others (families and friends).”

Source location

2016-0425-Response-by-Drug-Alcohol-Action-Team
Page 2 · response
Published 19 February 2017

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

Deliver regular AA and NA meetings on the islands.

Verbatim wording from the response

“A new Adults Recovery Co-ordinator has been appointed, with a brief to be more proactive. He has commenced fortnightly visits to the islands. He will also have back/replacement cover for sickness and annual leave, will establish a regular AA meeting on the islands, to replace the need for islanders having to travel to the mainland for this, and provide support for affected others (families and friends).”

Source location

2016-0425-Response-by-Drug-Alcohol-Action-Team
Page 2 · response
Published 19 February 2017

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

Commission at least fortnightly island visits delivering face-to-face recovery support, drop-ins, resources, detox access, prescribing, volunteer support and group therapy.

Verbatim wording from the response

“1. The contract we hold with Addaction requires a minimum of fortnightly island visits in 2017-18. This to deliver interventions which will include face-to-face contact with the Recovery Co-ordinator; a drop-in session; IOS specific resources; access to both home detox and community hospital detox; appropriate prescribing for medical problems; access to volunteer supporters; and group therapy. Visits can be supported, but not replaced, by Skype. Cover will be made available for any sickness or annual leave. Some of these services will be made available on the off islands, but this has yet to be worked up.”

Source location

2016-0425-Response-by-Drug-Alcohol-Action-Team
Page 2 · response
Published 19 February 2017

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