PFD report

Benjamin Popavach · Prevention of Future Deaths report

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Issued 23 Oct 2020•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.

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Concerns and recipient responses

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

Concerns raised1

  1. Failure to complete risk assessments for patients going on leave that identify community risks and agreed staff actions in case of plan breakdown
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.1

  1. Action

    Complete leave risk assessments identifying community risks and agreed staff actions if the plan breaks down.

    Stated by Devon Partnership NHS TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 4 December 2020.

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 complete risk assessments for patients going on leave that identify community risks and agreed staff actions in case of plan breakdown

Wider context from the report

“(2) At Page 20 of the Root Cause Analysis there is an outcome of the review listed under Immediate Changes – Ensure risk assessments are completed for patients going on leave, which identify risks in the community and agreed actions to be taken by staff in case of a breakdown in plan ”

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

Complete leave risk assessments identifying community risks and agreed staff actions if the plan breaks down.

Verbatim wording from the response

“Immediate changes | Ensure risk assessments are completed for patients going on leave, which identify risks in the community and agreed actions to be taken by staff in case of a breakdown in a plan. Sharing the learning | To be shared with ward staff and community teams”

Source location

2020-0214-Response-from-Devon-Partnership-NHS-Trust-Redacted.pdf
Page 2 · response
Published 4 December 2020

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.5

  1. 1

    Review the deceased’s family feedback to identify further learning and actions for inclusion in the existing action plan.

    Stated by Devon Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 December 2020.
  2. 2

    Discuss the review’s learning at the next available Medical Advisory Committee meeting.

    Stated by Devon Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 4 December 2020.
  3. 3

    Discuss the review’s learning at the Senior Nurse Forum.

    Stated by Devon Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 4 December 2020.
  4. 4

    Take the review’s learning to the Clinical Advisory Group and Safe from Suicide team for discussion, focusing on leave contingency plans and related learning.

    Stated by Devon Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 December 2020.
  5. 5

    Share the review’s learning with ward staff, community teams, medical staff, senior nurse managers, and relevant trust governance groups.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 4 December 2020.

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

  1. 1

    COVID-19 activity prevented the planned discussion of the report and learning at the Medical Advisory Committee meeting.

    Stated by Devon Partnership NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant 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

Review the deceased’s family feedback to identify further learning and actions for inclusion in the existing action plan.

Verbatim wording from the response

“I would like to note that following further contact from Benjamin's family we are currently reviewing their detailed feedback which we anticipate will identify further areas of potential learning and action for the trust. Any actions resulting from this work will be included in the original action plan.”

Source location

2020-0214-Response-from-Devon-Partnership-NHS-Trust-Redacted.pdf
Page 2 · response
Published 4 December 2020

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

Discuss the review’s learning at the next available Medical Advisory Committee meeting.

Verbatim wording from the response

“We had proposed to take this report and learning to the Medical Advisory Committee Meeting (MAC), however, due to the recent COVID activity this has not yet been possible. I can confirm that the learning from the review has been shared with all of our Medical Staff and the members of the MAC, it will also be added for further discussion at the next available meeting.”

Source location

2020-0214-Response-from-Devon-Partnership-NHS-Trust-Redacted.pdf
Page 2 · response
Published 4 December 2020

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

Discuss the review’s learning at the Senior Nurse Forum.

Verbatim wording from the response

“The learning from the review has been shared with our Senior Nurse Managers for sharing within their teams and will be taken to our Senior Nurse Forum for discussion.”

Source location

2020-0214-Response-from-Devon-Partnership-NHS-Trust-Redacted.pdf
Page 2 · response
Published 4 December 2020

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

Take the review’s learning to the Clinical Advisory Group and Safe from Suicide team for discussion, focusing on leave contingency plans and related learning.

Verbatim wording from the response

“Additionally, ████████, Deputy Medical Director is taking the learning to our Clinical Advisory Group which is a senior clinical forum for further discussion including our Safe from Suicide team with a particular focus on leave contingency plans and any other learning from the review.”

Source location

2020-0214-Response-from-Devon-Partnership-NHS-Trust-Redacted.pdf
Page 2 · response
Published 4 December 2020

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 review’s learning with ward staff, community teams, medical staff, senior nurse managers, and relevant trust governance groups.

Verbatim wording from the response

“Thank you for your letter of 23 October 2020 following the inquest into the death of Benjamin Popavach. 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

2020-0214-Response-from-Devon-Partnership-NHS-Trust-Redacted.pdf
Page 1 · response
Published 4 December 2020

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

COVID-19 activity prevented the planned discussion of the report and learning at the Medical Advisory Committee meeting.

Verbatim wording from the response

“We had proposed to take this report and learning to the Medical Advisory Committee Meeting (MAC), however, due to the recent COVID activity this has not yet been possible. I can confirm that the learning from the review has been shared with all of our Medical Staff and the members of the MAC, it will also be added for further discussion at the next available meeting.”

Source location

2020-0214-Response-from-Devon-Partnership-NHS-Trust-Redacted.pdf
Page 2 · response
Published 4 December 2020

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