PFD report

NICHOLAS JAMES GLAVIND DYMOND · Prevention of Future Deaths report

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Issued 21 Dec 2023•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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

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 raised2

  1. Failure to ensure independent s.12 doctors have access to patients’ records for Mental Health Act assessments
    Part of recurring concern: Unreliable access to relevant clinical records for safe care
  2. Lack of understanding of voluntary admission and the least restrictive option in Mental Health Act assessments
    Part of recurring concern: Failure to ensure timely and appropriate Mental Health Act assessment
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.2

  1. Action

    Implement the Devon Shared Care Record to facilitate cross-organisational access to clinical records.

    Stated by Devon Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 December 2023.
  2. Action

    Provide training enabling independent section 12 doctors to access CareNotes.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 December 2023.

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 ensure independent s.12 doctors have access to patients’ records for Mental Health Act assessments

Wider context from the report

“(1) The inquest heard that independent doctors did not have access to the CareNotes and relied upon printed copies of extracts from the notes which the AMHP considered pertinent to the Mental Health Act Assessment. Training is now available for independent s.12 doctors which, once completed, allows them access to CareNotes, but this training is not a mandated condition of their inclusion on the list of approved s.12 doctors. There remains a risk that, should a Trust doctor not be available to conduct the assessment, an independent doctor with no access to the patient’s records would be called upon to conduct an assessment. ”

Is this part of a recurring concern?

Yes — Unreliable access to relevant clinical records for safe care.

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 understanding of voluntary admission and the least restrictive option in Mental Health Act assessments

Wider context from the report

“(2) Several witnesses illustrated a lack of understanding of the concept of both a voluntary admission where a patient has undergone a Mental Health Act Assessment and of the ‘least restrictive option’. The opportunity for a patient to be admitted voluntarily for further assessment and treatment may therefore be missed. ”

Is this part of a recurring concern?

Yes — Failure to ensure timely and appropriate Mental Health Act assessment.

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

Implement the Devon Shared Care Record to facilitate cross-organisational access to clinical records.

Verbatim wording from the response

“The “Devon Shared Care Record” is also now being implemented. This will facilitate cross organisational access to clinical care records and so further improve availability of relevant information to clinicians.”

Source location

Response from Devon Partnership NHS Trust
Page 2 · response
Published 29 December 2023

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 training enabling independent section 12 doctors to access CareNotes.

Verbatim wording from the response

“The inquest heard that independent doctors did not have access to the CareNotes and relied upon printed copies of extracts from the notes which the AMHP considered pertinent to the Mental Health Act Assessment. Training is now available for independent s.12 doctors which, once completed, allows them access to CareNotes, but this training is not a mandated condition of their inclusion on the list of approved s.12 doctors. There remains a risk that, should a Trust doctor not be available to conduct the assessment, an independent doctor with no access to the patient’s records would be called upon to conduct an assessment.”

Source location

Response from Devon Partnership NHS Trust
Page 1 · response
Published 29 December 2023

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.7

  1. 1

    Use best endeavours to ensure at least one Mental Health Act assessing doctor is a Trust psychiatrist.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 December 2023.
  2. 2

    Operate Redhills Crisis House with 24-hour Trust staff for elective supported and crisis admissions.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 December 2023.
  3. 3

    Maintain an area-based duty rota providing an on-call section 12 Trust psychiatrist for Mental Health Act assessments.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 December 2023.
  4. 4

    Provide contracted supported beds for informal step-up and step-down patients in North Devon, clinically supported by home treatment teams.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 December 2023.
  5. 5

    Open 18 psychiatric rehabilitation beds across Devon to increase inpatient capacity for people with long-term psychosis.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 December 2023.
  6. 6

    Subject Mental Health Act assessments to audit by the Mental Health Act office and peer review by approved mental health professionals.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 December 2023.
  7. 7

    Redesign the Home Treatment Team by placing assessment within the First Response Team and delivering intensive support as an alternative to admission.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 December 2023.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The Trust cannot mandate training for approved section 12 doctors because their approval is outside its responsibility.

    Stated by Devon Partnership NHS TrustOutside remitThe respondent said that this matter was outside its role or authority.
  2. 2

    Winterhead Limited, acting for the Secretary of State, administers approval of section 12 doctors in the South West.

    Stated by Devon Partnership NHS TrustRedirects 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

Use best endeavours to ensure at least one Mental Health Act assessing doctor is a Trust psychiatrist.

Verbatim wording from the response

“As ████████ highlighted in her statement dated 19 September 2023, in Mr Dymond’s case, neither of the assessing doctors was a psychiatrist. As described above, whilst not a legal requirement, the Trust’s practice now is to make its best endeavours to ensure that at least one of the assessing doctors is a psychiatrist who works within the Trust.”

Source location

Response from Devon Partnership NHS Trust
Page 2 · response
Published 29 December 2023

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

Operate Redhills Crisis House with 24-hour Trust staff for elective supported and crisis admissions.

Verbatim wording from the response

“To that end, the Trust has opened Redhills Crisis house in Exeter. Redhills is not a registered hospital setting but offers supported and crisis admission with 24 hour Trust staff on an elective basis. On occasion people are moved from Redhills to a treatment ward, but more usually it is a short term, empowering and stabilising intervention designed to take people past the immediate point of risk to self.”

Source location

Response from Devon Partnership NHS Trust
Page 2 · response
Published 29 December 2023

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 an area-based duty rota providing an on-call section 12 Trust psychiatrist for Mental Health Act assessments.

Verbatim wording from the response

“The Trust endeavours to ensure that assessments under the Mental Health Act 1983 (“the MHA”) with no doctor from the Trust take place only in exceptional circumstances. As ████████ highlighted in her statement dated 19 September 2023, the Trust’s duty rota ensures that there is one s.12 MHA approved Trust psychiatrist ‘on call’ in each area, to attend MHA assessments.”

Source location

Response from Devon Partnership NHS Trust
Page 1 · response
Published 29 December 2023

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 contracted supported beds for informal step-up and step-down patients in North Devon, clinically supported by home treatment teams.

Verbatim wording from the response

“Repeat admissions to Redhills are accepted when people destabilise. Redhills accommodates people from Exeter, East and South, while we have contracted a number of supported beds for use as Step up from the community and /or step down from the wards in North Devon - these spaces are clinically supported by our home treatment teams and are solely accessible to informal patients.”

Source location

Response from Devon Partnership NHS Trust
Page 2 · response
Published 29 December 2023

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

Open 18 psychiatric rehabilitation beds across Devon to increase inpatient capacity for people with long-term psychosis.

Verbatim wording from the response

“The Trust has also opened in the interim period 18 psychiatric rehabilitation beds across Devon, which support people with long term psychosis. This further increases our inpatient capacity. Our Home Treatment Team (“HTT”) has also been redesigned since 2015 with the assessment function now sitting within the First Response Team and HTT delivering intensive support as an alternative to admission. The First Response Team is a service initially accessed by telephone and which undertakes triage, assessment, face to face contacts and onwards referrals for people in crisis.”

Source location

Response from Devon Partnership NHS Trust
Page 2 · response
Published 29 December 2023

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

Subject Mental Health Act assessments to audit by the Mental Health Act office and peer review by approved mental health professionals.

Verbatim wording from the response

“████████ has highlighted that the MHA assessments are subject to a robust audit process by both MHA office and AMHP peer review. AMHP managers discuss any matters and issues arising with individuals within the supervision process. It is a legal requirement for AMHPs to undertake statutory training in each year, failure to do so results in their approval and authority to practice being removed. This training ensures that legal knowledge is refreshed and current and also covers best practice and current challenges.”

Source location

Response from Devon Partnership NHS Trust
Page 3 · response
Published 29 December 2023

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

Redesign the Home Treatment Team by placing assessment within the First Response Team and delivering intensive support as an alternative to admission.

Verbatim wording from the response

“The Trust has also opened in the interim period 18 psychiatric rehabilitation beds across Devon, which support people with long term psychosis. This further increases our inpatient capacity. Our Home Treatment Team (“HTT”) has also been redesigned since 2015 with the assessment function now sitting within the First Response Team and HTT delivering intensive support as an alternative to admission. The First Response Team is a service initially accessed by telephone and which undertakes triage, assessment, face to face contacts and onwards referrals for people in crisis.”

Source location

Response from Devon Partnership NHS Trust
Page 2 · response
Published 29 December 2023

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

The Trust cannot mandate training for approved section 12 doctors because their approval is outside its responsibility.

Verbatim wording from the response

“The Trust has recently moved to a new electronic patient records system – Systm1 - which is widely used in Devon across the healthcare system, particularly within primary care, which means that most doctors are proficient in its use, although training is still offered if required. It is worth adding that the approval of s.12 MHA doctors is not a Trust responsibility, nor is it specific to our Trust. The Trust is not therefore able to make training a mandatory requirement of their inclusion on the list of doctors approved under s.12 MHA. In the South West, the approval of s12 doctors is undertaken by Winterhead Limited. Winterhead acts on behalf of the Secretary of State for Health to administer the approval of clinicians in the South of England to act as Approved Clinicians (AC) and doctors approved under section 12(2) of the Mental Health Act 1983.”

Source location

Response from Devon Partnership NHS Trust
Page 1 · response
Published 29 December 2023

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

Winterhead Limited, acting for the Secretary of State, administers approval of section 12 doctors in the South West.

Verbatim wording from the response

“The Trust has recently moved to a new electronic patient records system – Systm1 - which is widely used in Devon across the healthcare system, particularly within primary care, which means that most doctors are proficient in its use, although training is still offered if required. It is worth adding that the approval of s.12 MHA doctors is not a Trust responsibility, nor is it specific to our Trust. The Trust is not therefore able to make training a mandatory requirement of their inclusion on the list of doctors approved under s.12 MHA. In the South West, the approval of s12 doctors is undertaken by Winterhead Limited. Winterhead acts on behalf of the Secretary of State for Health to administer the approval of clinicians in the South of England to act as Approved Clinicians (AC) and doctors approved under section 12(2) of the Mental Health Act 1983.”

Source location

Response from Devon Partnership NHS Trust
Page 1 · response
Published 29 December 2023

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