PFD report

Name not published · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 6 Sep 2022•Plymouth, Torbay and South 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
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

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure to provide timely care and treatment
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

Failure to provide timely care and treatment

Wider context from the report

“(1) On the balance of probability there was a missed opportunity to afford timely care and treatment to the deceased before she was found in extremis on the 24th of February 2022. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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.6

  1. 1

    Disseminate a learning brief to NHS-commissioned healthcare providers on hygiene-related infection and sepsis risks and supporting people unable to maintain personal hygiene.

    Stated by NHS Devon Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
  2. 2

    Request commissioned health and independent services to review and amend relevant safeguarding policies, then obtain assurance of their review outcomes.

    Stated by NHS Devon Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 5 October 2022.
  3. 3

    Include learning from the case in the GP Bulletin and Devon LMC newsletter and discuss it with GP safeguarding leads at regular forums.

    Stated by NHS Devon Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 5 October 2022.
  4. 4

    Present the case learning and need to review and update multiagency safeguarding and adult social care policies at the PSAP and TDSAP partnership meetings.

    Stated by NHS Devon Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 5 October 2022.
  5. 5

    Request GP practices to review and amend safeguarding adult policies, and obtain assurance of the review outcomes.

    Stated by NHS Devon Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 5 October 2022.
  6. 6

    Review and amend NHS Devon ICB safeguarding adult policy to address self-neglect, hygiene-related infection and sepsis risks.

    Stated by NHS Devon Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.

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

  1. 1

    Each general practice is responsible for reviewing and maintaining its own safeguarding adult policies.

    Stated by NHS Devon Integrated Care BoardRedirects 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

Disseminate a learning brief to NHS-commissioned healthcare providers on hygiene-related infection and sepsis risks and supporting people unable to maintain personal hygiene.

Verbatim wording from the response

“NHS Devon ICB has reviewed its own safeguarding adult policies and has asked the safeguarding leads of those services that it commissions to review and update, if necessary, their safeguarding policies. A learning brief has been developed and disseminated to NHS commissioned healthcare providers to inform staff of this case and to support staff to understand that a lack of personal care and hygiene (including oral hygiene) can impact upon a person’s physical health and wellbeing and can lead to infection and sepsis; and to promote”

Source location

Response from Devon NHS
Page 1 · response
Published 5 October 2022

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

Request commissioned health and independent services to review and amend relevant safeguarding policies, then obtain assurance of their review outcomes.

Verbatim wording from the response

“NHS Devon Commissioned Services NHS Devon ICB | Safeguarding Adult Policy reviewed and amended NHS Commissioned Health Services | Letter sent to request review and amendment of relevant policies and confirmation of review and outcome by 7th November 2022. NHS Devon Head of Safeguarding will ensure that assurance is received from providers. Independent Commissioned Health Services | Letter sent to request review and amendment of relevant policies by 7th November 2022. NHS Devon Head of Safeguarding will ensure that assurance is received from providers.”

Source location

Response from Devon NHS
Page 2 · response
Published 5 October 2022

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 learning from the case in the GP Bulletin and Devon LMC newsletter and discuss it with GP safeguarding leads at regular forums.

Verbatim wording from the response

“Communication will be included in GP Bulletin and Devon LMC (Local Medical Committee) newsletter and learning from this case will be discussed at the regular fora held with GP Safeguarding Leads”

Source location

Response from Devon NHS
Page 2 · response
Published 5 October 2022

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

Present the case learning and need to review and update multiagency safeguarding and adult social care policies at the PSAP and TDSAP partnership meetings.

Verbatim wording from the response

“Safeguarding Adult Partnerships. As a partner of the two safeguarding adult partnerships in Devon; Torbay and Devon Safeguarding Adult Partnership (TDSAP) and Plymouth Safeguarding Adult Partnership (PSAP), NHS Devon will present the learning from this case and the need to ensure that multiagency safeguarding adult policies and adult social care policies are reviewed and updated, and changes disseminated to health and social care staff across the safeguarding partnerships. NHS Devon Head of Safeguarding will take a paper to the next Partnership meetings.”

Source location

Response from Devon NHS
Page 2 · response
Published 5 October 2022

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

Request GP practices to review and amend safeguarding adult policies, and obtain assurance of the review outcomes.

Verbatim wording from the response

“General Practice NHS Devon ICB has delegated commissioning responsibility for General Practice services in Devon and provides safeguarding support to GP practices. Each practice is responsible for their safeguarding policies. Many use the Royal College of General Practitioners (RCGP) safeguarding adult policy template.”

Source location

Response from Devon NHS
Page 2 · response
Published 5 October 2022

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 amend NHS Devon ICB safeguarding adult policy to address self-neglect, hygiene-related infection and sepsis risks.

Verbatim wording from the response

“NHS Devon ICB has reviewed its own safeguarding adult policies and has asked the safeguarding leads of those services that it commissions to review and update, if necessary, their safeguarding policies. A learning brief has been developed and disseminated to NHS commissioned healthcare providers to inform staff of this case and to support staff to understand that a lack of personal care and hygiene (including oral hygiene) can impact upon a person’s physical health and wellbeing and can lead to infection and sepsis; and to promote”

Source location

Response from Devon NHS
Page 1 · response
Published 5 October 2022

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

Each general practice is responsible for reviewing and maintaining its own safeguarding adult policies.

Verbatim wording from the response

“General Practice NHS Devon ICB has delegated commissioning responsibility for General Practice services in Devon and provides safeguarding support to GP practices. Each practice is responsible for their safeguarding policies. Many use the Royal College of General Practitioners (RCGP) safeguarding adult policy template.”

Source location

Response from Devon NHS
Page 2 · response
Published 5 October 2022

Open published response
Back to top

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