PFD report

Judith Anne SAVILLE · Prevention of Future Deaths report

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Issued 15 Jan 2015•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.

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Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
12

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 raised4

  1. Failure to implement the action plan arising from the Root Cause Analysis
    Part of recurring concern: Failure to implement identified safety actionsPart of recurring concern: Unreliable root cause analysis processes
  2. Failure to limit medication supplies for patients with a history of prescribed-medication overdose
    Part of recurring concern: Failure to apply overdose-risk safeguards to medication prescribingPart of recurring concern: Medication quantity controls failing to prevent unsafe access to excessive amountsPart of recurring concern: Unsafe medication prescribing
  3. Lack of a computer-system warning for patients with a history of overdose
    Part of recurring concern: Failure to apply overdose-risk safeguards to medication prescribing
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.10

  1. Action

    Reassess CRHT patients before discharge when increased risks have been identified.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
  2. Action

    Document discharge awareness and routinely consult and inform people and carers about CRHT discharge decisions.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
  3. Action

    Have CRHT staff attend weekly Rougemont discharge-planning meetings to improve Adult/OPMH communication.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    Restricting prescriptions cannot prevent patients from stockpiling regular medication or accessing other toxic medicines, including over-the-counter drugs.

    Stated by Axminster Medical PracticeUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 implement the action plan arising from the Root Cause Analysis

Wider context from the report

“(2) For the attention of Melanie Walker The Inquest heard evidence from ████████████████████ who had conducted a Root Cause Analysis into the circumstances of Mrs Saville’s death. A copy of that Report is attached. ████████ gave evidence that there were a number of lessons to be learned and that an action plan had been drafted. At Inquest I expressed my concern that the action plan was implemented and its effectiveness subsequently audited. ”

Is this part of a recurring concern?

Yes — Failure to implement identified safety actions; Unreliable root cause analysis processes.

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 limit medication supplies for patients with a history of prescribed-medication overdose

Wider context from the report

“(1) For the attention of ████████ In his evidence ████████ told the Court that Mrs Saville’s death had been reviewed at a significant events meeting in his practice. I was told that it was felt he had prescribed too much medication, particularly as the person who had a past medical history that included overdoses of prescribed medication. ████████ said that there was now an increased awareness on the Practitioners not to prescribe so much medication in similar circumstances. He felt that a supply of no more than a week’s worth of medication would be appropriate. ████████ said that the system could be made more robust by introducing a warning on the firm’s computer system. This would assist Practitioners by drawing to their attention a past medical history of overdose. It was felt that this may particularly be of benefit to locum doctors who would not necessarily have the same recall of a patient as a partner in the practice. ”

Is this part of a recurring concern?

Yes — Failure to apply overdose-risk safeguards to medication prescribing; Medication quantity controls failing to prevent unsafe access to excessive amounts; Unsafe medication prescribing.

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 a computer-system warning for patients with a history of overdose

Wider context from the report

“(1) For the attention of ████████ In his evidence ████████ told the Court that Mrs Saville’s death had been reviewed at a significant events meeting in his practice. I was told that it was felt he had prescribed too much medication, particularly as the person who had a past medical history that included overdoses of prescribed medication. ████████ said that there was now an increased awareness on the Practitioners not to prescribe so much medication in similar circumstances. He felt that a supply of no more than a week’s worth of medication would be appropriate. ████████ said that the system could be made more robust by introducing a warning on the firm’s computer system. This would assist Practitioners by drawing to their attention a past medical history of overdose. It was felt that this may particularly be of benefit to locum doctors who would not necessarily have the same recall of a patient as a partner in the practice. ”

Is this part of a recurring concern?

Yes — Failure to apply overdose-risk safeguards to medication prescribing.

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 audit the effectiveness of the action plan

Wider context from the report

“(2) For the attention of Melanie Walker The Inquest heard evidence from ████████████████████ who had conducted a Root Cause Analysis into the circumstances of Mrs Saville’s death. A copy of that Report is attached. ████████ gave evidence that there were a number of lessons to be learned and that an action plan had been drafted. At Inquest I expressed my concern that the action plan was implemented and its effectiveness subsequently audited. ”

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

Reassess CRHT patients before discharge when increased risks have been identified.

Verbatim wording from the response

“Action 2 Recommendation: That the CRHT team reassess individuals prior to discharge where increased risks have been highlighted.”

Source location

2015-0011-Response-by-Devon-Partnership-NHS-Trust
Page 2 · response
Published 15 January 2015

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

Document discharge awareness and routinely consult and inform people and carers about CRHT discharge decisions.

Verbatim wording from the response

“Action 4 Recommendation: That RiO notes and recovery plans regarding the discharge of people from the CRHT team clearly state whether the person involved and their carers are aware of the discharge.”

Source location

2015-0011-Response-by-Devon-Partnership-NHS-Trust
Page 3 · response
Published 15 January 2015

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

Have CRHT staff attend weekly Rougemont discharge-planning meetings to improve Adult/OPMH communication.

Verbatim wording from the response

“Action 6 Recommendation: That the OPMH team and the CRHT team carry out a review of how to improve communication between teams with recommendations and actions reported into the CRHT team and OPMH team.”

Source location

2015-0011-Response-by-Devon-Partnership-NHS-Trust
Page 3 · response
Published 15 January 2015

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

Record all telephone calls received by CRHT teams in clinical records.

Verbatim wording from the response

“Action 3 Recommendation: That all phone calls received by CRHT teams are recorded in the clinical record.”

Source location

2015-0011-Response-by-Devon-Partnership-NHS-Trust
Page 2 · response
Published 15 January 2015

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

Increase OPMH consultant input and provide CRHT teams with direct access to OPMH consultants or named backup.

Verbatim wording from the response

“Action 6 Recommendation: That the OPMH team and the CRHT team carry out a review of how to improve communication between teams with recommendations and actions reported into the CRHT team and OPMH team.”

Source location

2015-0011-Response-by-Devon-Partnership-NHS-Trust
Page 3 · response
Published 15 January 2015

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

Register both CRHT teams for the Triangle of Care initiative.

Verbatim wording from the response

“Action to address recommendation: That the CRHT team CTL communicates the importance of the clinical record indicating that people using the service and their carers are aware of discharge. That carers are being informed about discharge by both CRHT being signed up to the Triangle of Care initiative and is also monitored by CRSM/random audits.”

Source location

2015-0011-Response-by-Devon-Partnership-NHS-Trust
Page 3 · response
Published 15 January 2015

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 recovery plans face to face with people using CRHT services whenever safe and practicable.

Verbatim wording from the response

“Action 7 Recommendation: That all cases open to the CRHT team have a recovery plan that is developed face to face with the individual.”

Source location

2015-0011-Response-by-Devon-Partnership-NHS-Trust
Page 4 · response
Published 15 January 2015

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

Consider the wishes and opinions of people receiving services in clinical decision making.

Verbatim wording from the response

“Action 8 Recommendation: That the wishes and opinions of people receiving services are always considered in the clinical decision-making process.”

Source location

2015-0011-Response-by-Devon-Partnership-NHS-Trust
Page 4 · response
Published 15 January 2015

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 comprehensive assessments and formulate recovery, care and risk plans for people using CRHT services.

Verbatim wording from the response

“Action 1 Recommendation: That Crisis Teams should provide a comprehensive assessment (including a full mental state assessment) for all people using the service, required for the recovery plan. From this a recovery / care plan and risk assessment (including information of known risks) should be formulated to meet and manage identified needs and risks.”

Source location

2015-0011-Response-by-Devon-Partnership-NHS-Trust
Page 2 · response
Published 15 January 2015

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

Contact people on the day they are discharged from CRHT, using face-to-face or telephone contact according to risk.

Verbatim wording from the response

“Action 5 Recommendation: That, unless clinically indicated otherwise, the CRHT team always contact people (face to face or telephone) on the day that they are discharged from the team.”

Source location

2015-0011-Response-by-Devon-Partnership-NHS-Trust
Page 3 · response
Published 15 January 2015

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

Restricting prescriptions cannot prevent patients from stockpiling regular medication or accessing other toxic medicines, including over-the-counter drugs.

Verbatim wording from the response

“Our local pharmacists and dispensers do also flag to us when patients appear to be receiving medications earlier than would be expected. As you will understand however, restricting prescribed medications would not prevent patients who have chosen to “stockpile” regular medications from holding large numbers of any pill which we prescribe regularly. There are many medications which are much more toxic than zopiclone and of course many over the counter medications which would also be toxic in overdose.”

Source location

2015-0011-Response-by-Axminster-Medical-Practice
Page 1 · response
Published 15 January 2015

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

Existing computer prescribing prompts and pharmacist or dispenser alerts are considered sufficient safeguards for zopiclone prescribing.

Verbatim wording from the response

“In the situation in which normally we prescribe Zopiclone, short courses of limited numbers of pills are advisable and our computer system automatically offers us this choice with a label which advises against repeat or regular use. There will inevitably be some patients for whom it has been decided that a regular prescription of one months supply is appropriate. In Mrs Saville’s particular circumstance we would not necessarily agree that ████████ prescribed too many zopiclone pills, although we sympathise with his comments. Viewing her prescribing records it appears that she was not prescribed on any single occasion more than a months supply at the dose ████████ had decided on. We would certainly all agree that in cases where there is a heightened risk of suicide we would endeavour to restrict all supplies of potentially toxic medication of any type.”

Source location

2015-0011-Response-by-Axminster-Medical-Practice
Page 1 · response
Published 15 January 2015

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 practice does not agree that too many zopiclone pills were prescribed, as no single prescription exceeded one month’s supply.

Verbatim wording from the response

“In the situation in which normally we prescribe Zopiclone, short courses of limited numbers of pills are advisable and our computer system automatically offers us this choice with a label which advises against repeat or regular use. There will inevitably be some patients for whom it has been decided that a regular prescription of one months supply is appropriate. In Mrs Saville’s particular circumstance we would not necessarily agree that ████████ prescribed too many zopiclone pills, although we sympathise with his comments. Viewing her prescribing records it appears that she was not prescribed on any single occasion more than a months supply at the dose ████████ had decided on. We would certainly all agree that in cases where there is a heightened risk of suicide we would endeavour to restrict all supplies of potentially toxic medication of any type.”

Source location

2015-0011-Response-by-Axminster-Medical-Practice
Page 1 · response
Published 15 January 2015

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 special flag for previous overdoses is considered problematic because it may be irrelevant, misleading, judgemental or offensive.

Verbatim wording from the response

“To have a special flag which highlights that a patient has taken overdoses in the past would be problematic because this is not relevant information for many such people and significant numbers of patient have taken overdoses in the past but are not at increased risk of repeating any form of self-harm. Patients rightly expect that their medical records are both accurate and do not stress information which might in some way be viewed as judgemental and a special flag or message which is given more weight than any other part of their medical history might well be offensive to some.”

Source location

2015-0011-Response-by-Axminster-Medical-Practice
Page 2 · response
Published 15 January 2015

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

Routine review of the accessible medical-record summary is considered sufficient to identify relevant previous overdoses during patient assessment.

Verbatim wording from the response

“Your recommendations have lead us to consider the methods available to GPs in assessing whether a patient might have an increased risk of suicide. Mrs Saville’s medical records record clearly in the summary that she had taken two overdoses, one in 1994 after what is described as a marriage break-up and another in 2010. All the GP’s agreed that it would be a normal part of assessing a patient to look at the summary page which is clear and easily accessible. All the information contained therein would naturally be taken into account especially if it is relevant to the reason a patient is consulting.”

Source location

2015-0011-Response-by-Axminster-Medical-Practice
Page 2 · response
Published 15 January 2015

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.2

  1. 1

    Share the coroner’s findings with the involved service and across the wider Trust.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
  2. 2

    Consider methods available to GPs for assessing whether patients have an increased suicide risk.

    Stated by Axminster Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.4

  1. 1

    Discharge contact may be by telephone rather than face to face where the discharge risk assessment supports that approach.

    Stated by Devon Partnership NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. 2

    Face-to-face recovery-plan development may not be possible when people are acutely unwell or compelled, or until it is safe.

    Stated by Devon Partnership NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  3. 3

    Crisis Team assessment and prescribing guidance are considered sufficient to manage patients identified as having heightened suicide risk.

    Stated by Axminster Medical PracticeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  4. 4

    The Local Medical Committee is identified as the body that could advise the wider GP community on the proposed approach.

    Stated by Axminster Medical PracticeRedirects 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

Share the coroner’s findings with the involved service and across the wider Trust.

Verbatim wording from the response

“Thank you for your letter of the 15th January 2015 which we received on the 20th January 2015 following the inquest into the death of Judith Anne Saville. 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

2015-0011-Response-by-Devon-Partnership-NHS-Trust
Page 1 · response
Published 15 January 2015

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

Consider methods available to GPs for assessing whether patients have an increased suicide risk.

Verbatim wording from the response

“Your recommendations have lead us to consider the methods available to GPs in assessing whether a patient might have an increased risk of suicide. Mrs Saville’s medical records record clearly in the summary that she had taken two overdoses, one in 1994 after what is described as a marriage break-up and another in 2010. All the GP’s agreed that it would be a normal part of assessing a patient to look at the summary page which is clear and easily accessible. All the information contained therein would naturally be taken into account especially if it is relevant to the reason a patient is consulting.”

Source location

2015-0011-Response-by-Axminster-Medical-Practice
Page 2 · response
Published 15 January 2015

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

Discharge contact may be by telephone rather than face to face where the discharge risk assessment supports that approach.

Verbatim wording from the response

“Action 5 Recommendation: That, unless clinically indicated otherwise, the CRHT team always contact people (face to face or telephone) on the day that they are discharged from the team.”

Source location

2015-0011-Response-by-Devon-Partnership-NHS-Trust
Page 3 · response
Published 15 January 2015

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

Face-to-face recovery-plan development may not be possible when people are acutely unwell or compelled, or until it is safe.

Verbatim wording from the response

“Action 7 Recommendation: That all cases open to the CRHT team have a recovery plan that is developed face to face with the individual.”

Source location

2015-0011-Response-by-Devon-Partnership-NHS-Trust
Page 4 · response
Published 15 January 2015

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

Crisis Team assessment and prescribing guidance are considered sufficient to manage patients identified as having heightened suicide risk.

Verbatim wording from the response

“In Mrs Saville’s case it is important to consider what action might have resulted if there had been a flag which suggested an increased risk of suicide. All the GP’s present agreed that this might have prompted urgent referral to the Crisis Response Team for an assessment including the current suicide risk. The Crisis Team always guide us if they believe that a heightened risk should temporarily (or permanently) change our patterns of prescribing. I understand that this referral was made and Mrs Saville was seen.”

Source location

2015-0011-Response-by-Axminster-Medical-Practice
Page 2 · response
Published 15 January 2015

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 Local Medical Committee is identified as the body that could advise the wider GP community on the proposed approach.

Verbatim wording from the response

“I believe the wider GP community as a whole is likely to hold similar views and if you wish this could be raised with the Local Medical Committee who could advise us accordingly.”

Source location

2015-0011-Response-by-Axminster-Medical-Practice
Page 2 · response
Published 15 January 2015

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