PFD report

Matthew Llewellyn-Jones · Prevention of Future Deaths report

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Issued 25 Oct 2016•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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
11

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.

Report evidence summary

Concerns raised4

  1. Failure of the admission recording system to make obtaining carer and family information mandatory
    Part of recurring concern: Failure to obtain relevant collateral information from family and social supportsPart of recurring concern: Incomplete clinical history-takingPart of recurring concern: Unreliable admission assessment of patientsPart of recurring concern: Unreliable completion of admission documentation
  2. Failure to secure the ward door
  3. Failure of ward policy to require unpredictable and irregular observations
    Part of recurring concern: Unreliable observation of patients in specialist mental health unitsPart of recurring concern: Unreliable patient observation arrangements
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.5

  1. Action

    Activate a Care Notes risk-assessment area recording carers’ and family members’ views.

    Stated by Devon Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 25 October 2016.
  2. Action

    Use an active Care Notes care-planning field to record information sought from carers or family.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 25 October 2016.
  3. Action

    Maintain locked Cedars doors, warning signage, admission information and supportive engagement procedures before patients leave.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 25 October 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    A mandatory field for carer and family information will not be added; free-text recording and audit follow-up are considered sufficient.

    Stated by Devon Partnership NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 the admission recording system to make obtaining carer and family information mandatory

Wider context from the report

“(3) A new system of note recording has been introduced since this death, but it still does not make obtaining information from carers and/or family mandatory on admission. The importance of this information was readily acknowledged by the Trust in their internal inquiry and at inquest. The electronic recording system should be able to facilitate capturing such information with the use of mandatory fields to avoid this oversight and could assist the Trust in achieving their stated aims in this respect. ”

Is this part of a recurring concern?

Yes — Failure to obtain relevant collateral information from family and social supports; Incomplete clinical history-taking; Unreliable admission assessment of patients; Unreliable completion of admission documentation.

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 to secure the ward door

Wider context from the report

“(1) The Devon Partnership trust acknowledged in inquest that the "locked door" is still being breached on occasion, as identified on audit. An electronic pad or sign has been considered to offer clearer indications of when the door should be secured, but not yet trialled or actioned. The door therefore remains an ongoing security risk for the ward. ”

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

Failure of ward policy to require unpredictable and irregular observations

Wider context from the report

“(2) Observations when carried out in the context of a secure mental health environment should not be predictable or entirely regular. This is not currently part of the ward policy, although it appeared to be accepted by senior staff at inquest. The Trust should consider further measures to ensure that training and instruction given to all staff in relation to observations is clear, constantly reinforced, and in line with best practise. ”

Is this part of a recurring concern?

Yes — Unreliable observation of patients in specialist mental health units; Unreliable patient observation arrangements.

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 to provide clear and consistently reinforced observation training and instruction

Wider context from the report

“(2) Observations when carried out in the context of a secure mental health environment should not be predictable or entirely regular. This is not currently part of the ward policy, although it appeared to be accepted by senior staff at inquest. The Trust should consider further measures to ensure that training and instruction given to all staff in relation to observations is clear, constantly reinforced, and in line with best practise. ”

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

Activate a Care Notes risk-assessment area recording carers’ and family members’ views.

Verbatim wording from the response

“• Risk Assessment (Specific area looking at carer/family views) – this is due to become active by the end of January 2017 (ref 2.2)”

Source location

2016-0385-Response-by-Devon-Partnership-NHS-Trust
Page 2 · response
Published 25 October 2016

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 an active Care Notes care-planning field to record information sought from carers or family.

Verbatim wording from the response

“A copy of the Care Notes forms are attached, the specific changes that have been made are-”

Source location

2016-0385-Response-by-Devon-Partnership-NHS-Trust
Page 2 · response
Published 25 October 2016

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

Maintain locked Cedars doors, warning signage, admission information and supportive engagement procedures before patients leave.

Verbatim wording from the response

“• The doors at the Cedars have been ‘locked’ since the inquest. Review continues as outlined in the Entry and Exit policy. Entrances to our in-patient units have notification that the door is locked. Patients are informed of the locked door position on admission and the process of supportive engagement prior to leave.”

Source location

2016-0385-Response-by-Devon-Partnership-NHS-Trust
Page 1 · response
Published 25 October 2016

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

Finalize and implement revised Engagement Policy requirements for documenting and varying intermittent engagement and observation intervals.

Verbatim wording from the response

“The ‘Engagement Policy’ has been reviewed by the Deputy Director of Nursing and is currently being finalised, it has been changed to include the following -”

Source location

2016-0385-Response-by-Devon-Partnership-NHS-Trust
Page 1 · response
Published 25 October 2016

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 revise the Entry and Exit Policy to support locked doors across inpatient units while protecting patients’ rights to exit.

Verbatim wording from the response

“• The locked door and permanently locking has been discussed at our Senior Management Board and it has been agreed that the Entry and Exit Policy is reviewed with a recommendation for locked doors on all of our in-patient units.”

Source location

2016-0385-Response-by-Devon-Partnership-NHS-Trust
Page 1 · response
Published 25 October 2016

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

A mandatory field for carer and family information will not be added; free-text recording and audit follow-up are considered sufficient.

Verbatim wording from the response

“The introduction of a mandatory field has been considered by the Care Notes team and senior clinical colleagues. The decision has been made not to add as a mandatory field, it will continue to be recorded as a ‘free text’ field. The rational for this decision is that a mandatory field could be completed with a generic comment for example ‘have been unable to contact family at this time’, when audited as detailed below, this would be identified as completed. If the field is left ‘blank’ the audit will highlight this and allow individual review and follow up with the staff member concerned.”

Source location

2016-0385-Response-by-Devon-Partnership-NHS-Trust
Page 2 · response
Published 25 October 2016

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.6

  1. 1

    Publish the revised Engagement Policy across the Trust and share it with Adult Directorate colleagues.

    Stated by Devon Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 25 October 2016.
  2. 2

    Use an observation recording form requiring the specific time of each patient observation.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 25 October 2016.
  3. 3

    Install LED signs indicating when ward doors are locked.

    Stated by Devon Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 October 2016.
  4. 4

    Monitor compliance with the Engagement Policy through the Quality Monitoring Tool.

    Stated by Devon Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 October 2016.
  5. 5

    Monitor Care Notes recording changes through service-specific quality reviews, feedback, practice discussions and governance reporting.

    Stated by Devon Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 October 2016.
  6. 6

    Develop and implement a single Assessment and Review format for all services.

    Stated by Devon Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 October 2016.

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 the revised Engagement Policy across the Trust and share it with Adult Directorate colleagues.

Verbatim wording from the response

“The revised policy will be published in January 2017 across the Trust and will be shared directly with colleagues in the Adult Directorate in its Directorate Bulletin in January 2017.”

Source location

2016-0385-Response-by-Devon-Partnership-NHS-Trust
Page 2 · response
Published 25 October 2016

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 an observation recording form requiring the specific time of each patient observation.

Verbatim wording from the response

“The form used for recording observations had been changed at the time of the inquest and now requires the specific time of observation to be recorded on the form for each patient.”

Source location

2016-0385-Response-by-Devon-Partnership-NHS-Trust
Page 2 · response
Published 25 October 2016

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

Install LED signs indicating when ward doors are locked.

Verbatim wording from the response

“• LED signs for doors have been ordered and we are waiting for them to be delivered and installed. These are due to be installed within the next month.”

Source location

2016-0385-Response-by-Devon-Partnership-NHS-Trust
Page 1 · response
Published 25 October 2016

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

Monitor compliance with the Engagement Policy through the Quality Monitoring Tool.

Verbatim wording from the response

“A copy of the recording form is attached for information (ref 1.0). New or temporary staff are briefed on team practices as part of their local induction. Compliance with the engagement policy is monitored via the Quality Monitoring Tool; adjustments to the relevant quality areas will be actioned upon ratification of policies.”

Source location

2016-0385-Response-by-Devon-Partnership-NHS-Trust
Page 2 · response
Published 25 October 2016

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

Monitor Care Notes recording changes through service-specific quality reviews, feedback, practice discussions and governance reporting.

Verbatim wording from the response

“The compliance with this change in practice will be monitored and reported using the new ‘Quality Monitoring Review Tool’, this focuses on assessing the quality of record keeping as part of delivering overall high quality, safe and effective care. A copy of the Quality Monitoring Review Tool and an example of the Inpatient Team Quality Monitoring RAG feedback report are attached for information (ref 3.1 and 3.2)”

Source location

2016-0385-Response-by-Devon-Partnership-NHS-Trust
Page 2 · response
Published 25 October 2016

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 implement a single Assessment and Review format for all services.

Verbatim wording from the response

“• A new single Assessment & Review format for all services is being developed - work to date is attached. Implementation date is by end of February 2017. (ref 2.3)”

Source location

2016-0385-Response-by-Devon-Partnership-NHS-Trust
Page 2 · response
Published 25 October 2016

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

Official responses located
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Data last updated 7 September 2026