PFD report

Glenn Macmartin · Prevention of Future Deaths report

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Issued 7 May 2021•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.

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Concerns
1

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
16

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 physically inspect accommodation suitability before placement
    Part of recurring concern: Inadequate assessment of care needs before accepting patients into care
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.4

  1. Action

    Develop an out-of-area placement protocol and provider monitoring form covering suitability assurances and face-to-face reviews.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 May 2021.
  2. Action

    Link community and forensic social work teams to standardise placement sourcing and review and ensure proposed placements reach the contract and review team before contracting.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 May 2021.
  3. Action

    Complete a social care delivery redesign with dedicated community mental health social workers responsible for sourcing and reviewing placements.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 May 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The local authority has a role in selecting and monitoring care services, including safeguarding, and is expected to address that role.

    Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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 physically inspect accommodation suitability before placement

Wider context from the report

“(1) The deceased was accommodated in a Care Home that was subsequently formally closed due to poor service. The selection of the accommodation was made without a physical inspection of its suitability for the deceased by the organisation with responsibility for providing the accommodation before the deceased took up residence. ”

Is this part of a recurring concern?

Yes — Inadequate assessment of care needs before accepting patients into care.

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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 an out-of-area placement protocol and provider monitoring form covering suitability assurances and face-to-face reviews.

Verbatim wording from the response

“• A protocol to specifically address the placing of people outside of the Trust’s geographical area has been developed. This will strengthen our existing practice by providing a clear guide for our teams and follows the guidance within the advice note for directors and of adult social services commissioning out of area care and support services produced by ADASS. It also highlights the need to ensure the provider has arrangements in place and contains provisions to assure of suitability of service and face to face reviews. The Trust has also developed an Out of County Care Provider Monitoring form as part of its provider assurance service. I attach the protocol and Monitoring form for your information.”

Source location

Response-from-Wonford-House-Hospital
Page 4 · response
Published 7 May 2021

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

Link community and forensic social work teams to standardise placement sourcing and review and ensure proposed placements reach the contract and review team before contracting.

Verbatim wording from the response

“• The community social work managers have linked with the forensic social work team at Langdon Hospital (a secure service for which the Trust is responsible, and where Mr MacMartin had been detained) to strengthen links and ensure that processes and practice relating to the sourcing and review of social care is uniform across all services and that the contract and review team are fully cited on all proposed placements prior to any contracting taking place;”

Source location

Response-from-Wonford-House-Hospital
Page 4 · response
Published 7 May 2021

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

Complete a social care delivery redesign with dedicated community mental health social workers responsible for sourcing and reviewing placements.

Verbatim wording from the response

“• A redesign of social care delivery within the Trust is now complete, with dedicated social workers in each community mental health team, who are responsible for both the sourcing and review of social care placements and support;”

Source location

Response-from-Wonford-House-Hospital
Page 3 · response
Published 7 May 2021

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

Inspect new provider facilities before contracting to assure placement suitability.

Verbatim wording from the response

“In line with the evidence set given by ████████ at the Inquest, in the time since Mr MacMartin’s death, a decision has been made that mental health social care will not contract with new providers without visiting the facilities to gain assurance of suitability.”

Source location

Response-from-Wonford-House-Hospital
Page 2 · response
Published 7 May 2021

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 authority has a role in selecting and monitoring care services, including safeguarding, and is expected to address that role.

Verbatim wording from the response

“We recognise that the Local Authority also has a role in selection and monitoring of a service, as well as in relation to safeguarding. We anticipate the Local Authority will summarise this role in their response to the Regulation 28 report.”

Source location

Response from CQC
Page 3 · response
Published 7 May 2021

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 CQC ratings, contractual quality provisions and placement experience were considered sufficient assurance that the care home was appropriate.

Verbatim wording from the response

“The Trust does reasonably rely on the inspections and ratings provided by the CQC in terms of quality assurance and adherence to any relevant regulations. I understand that at the time of Mr MacMartin’s placement at Annette’s Care Home (“the Care Home”) in Plymouth the corresponding CQC report was reviewed. It was confirmed that the Care Home was rated by the CQC as “Good”. Furthermore, at the time Devon County Council had an existing contract in place with the Care Home. The contract for services entered into included the following provisions around quality assurance:”

Source location

Response-from-Wonford-House-Hospital
Page 2 · response
Published 7 May 2021

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.12

  1. 1

    Agree the learning review’s terms of reference and scope with partner agencies.

    Stated by Plymouth Safeguarding Adults PartnershipStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021.
  2. 2

    Share the learning from the independently facilitated multi-agency review as widely as possible.

    Stated by Plymouth Safeguarding Adults PartnershipStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021.
  3. 3

    Identify and commission an independent facilitator for the multi-agency learning review.

    Stated by Plymouth Safeguarding Adults PartnershipStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021.
  4. 4

    Capture the learning, produce a report, and provide it to the Coroner.

    Stated by Plymouth Safeguarding Adults PartnershipStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021.
  5. 5

    Inform relevant partner agencies about the learning review proposal and secure their engagement.

    Stated by Plymouth Safeguarding Adults PartnershipStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021.
  6. 6

    Complete an internal review of regulatory actions concerning Annette’s Care and the care provided to Mr MacMartin.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 7 May 2021.
  7. 7

    Consider recommendations arising from the multi-agency learning event.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021.
  8. 8

    Participate in a multi-agency learning event to improve coordination and identify lessons from the case.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 7 May 2021.
  9. 9

    Maintain collaboration between social work, contract and review teams through scheduled monthly meetings.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 May 2021.
  10. 10

    Introduce a Local Authority-assigned social worker into the community forensic team to link social care and forensic services during transitions.

    Stated by Devon Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021.
  11. 11

    Undertake Root Cause Analysis investigations when incident thresholds are met, identifying causes, actions, responsibilities and deadlines.

    Stated by Devon Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021.
  12. 12

    Complete Care Act-compliant assessments documenting needs, strengths, wishes and networks to inform care plans and commissioning.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 May 2021.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.7

  1. 1

    The referral did not meet Safeguarding Adult Review criteria because investigations found no crime, abuse, neglect, or related safeguarding failure.

    Stated by NHS Devon Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    Internal review found no gaps or improvement areas in monitoring, inspection or enforcement methodology; existing actions were timely, justified and proportionate.

    Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  3. 3

    The evidence was insufficient to establish provider-level failure causing avoidable harm or significant risk to the deceased.

    Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  4. 4

    Devon Partnership Trust was responsible for commissioning the deceased’s care and reviewing its ongoing quality and support.

    Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  5. 5

    Partner agencies, including the local authority and commissioners, were responsible for arranging residents’ alternative homes after closure.

    Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  6. 6

    The relevant Local Authority is responsible for determining whether safeguarding investigations are required and who should undertake them.

    Stated by Devon Partnership NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  7. 7

    The CQC is responsible for monitoring, reviewing and enforcing applicable regulatory requirements for care homes.

    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

Agree the learning review’s terms of reference and scope with partner agencies.

Verbatim wording from the response

“I understand that planning for the learning review is underway, and the following details of this will be communicated to Mr MacMartin’s family and to HMCO as the response to the Regulation 28 request.”

Source location

Response-from-Plymouth-Safeguarding-Adults-Partnership
Page 3 · response
Published 7 May 2021

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 learning from the independently facilitated multi-agency review as widely as possible.

Verbatim wording from the response

“I endorse the recommendation not to proceed to a SAR process based on the detailed rationale set out above. However, I fully support the commissioning of a multi-agency learning review, independently facilitated, to ensure that multi-agency learning is identified in terms of strengths and weaknesses, and subsequently translated into improved ways of working across the system. This should be a transparent process involving the engagement and participation of Mr MacMartin’s family, with the learning shared as widely as possible.”

Source location

Response-from-Plymouth-Safeguarding-Adults-Partnership
Page 3 · response
Published 7 May 2021

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

Identify and commission an independent facilitator for the multi-agency learning review.

Verbatim wording from the response

“I endorse the recommendation not to proceed to a SAR process based on the detailed rationale set out above. However, I fully support the commissioning of a multi-agency learning review, independently facilitated, to ensure that multi-agency learning is identified in terms of strengths and weaknesses, and subsequently translated into improved ways of working across the system. This should be a transparent process involving the engagement and participation of Mr MacMartin’s family, with the learning shared as widely as possible.”

Source location

Response-from-Plymouth-Safeguarding-Adults-Partnership
Page 3 · response
Published 7 May 2021

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

Capture the learning, produce a report, and provide it to the Coroner.

Verbatim wording from the response

“I understand that planning for the learning review is underway, and the following details of this will be communicated to Mr MacMartin’s family and to HMCO as the response to the Regulation 28 request.”

Source location

Response-from-Plymouth-Safeguarding-Adults-Partnership
Page 3 · response
Published 7 May 2021

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

Inform relevant partner agencies about the learning review proposal and secure their engagement.

Verbatim wording from the response

“I understand that planning for the learning review is underway, and the following details of this will be communicated to Mr MacMartin’s family and to HMCO as the response to the Regulation 28 request.”

Source location

Response-from-Plymouth-Safeguarding-Adults-Partnership
Page 3 · response
Published 7 May 2021

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

Complete an internal review of regulatory actions concerning Annette’s Care and the care provided to Mr MacMartin.

Verbatim wording from the response

“The CQC has undertaken an internal review of the actions it took in relation to Annette’s Care Limited and the case of Mr MacMartin. We are satisfied that the decision taken to inspect Annette’s Care was timely, proportionate and justified, and complied with CQC methodology. We are also satisfied that the determination not to proceed to a formal criminal investigation following the initial assessment was also proportionate, justified and in line with CQC methodology. These assessments will be reconsidered in light of any recommendations made or findings from the joint agency Learning Event, which we refer to later in this response.”

Source location

Response from CQC
Page 2 · response
Published 7 May 2021

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 recommendations arising from the multi-agency learning event.

Verbatim wording from the response

“The CQC are participating in a ‘learning event’ with Devon and Cornwall Police, Devon Partnership Trust and Plymouth County Council (Commissioning and Adult Safeguarding) as part of our continuing effort to improve coordination of CQC and Local Authority actions, and to learn any relevant lessons, individually and/or collectively. Following the conclusion of the learning event we will consider any recommendations. Unfortunately, the family have not been available to participate which has had an impact on the progress of the learning event. We look forward to meeting with the family when they are available.”

Source location

Response from CQC
Page 4 · response
Published 7 May 2021

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

Participate in a multi-agency learning event to improve coordination and identify lessons from the case.

Verbatim wording from the response

“The CQC are participating in a ‘learning event’ with Devon and Cornwall Police, Devon Partnership Trust and Plymouth County Council (Commissioning and Adult Safeguarding) as part of our continuing effort to improve coordination of CQC and Local Authority actions, and to learn any relevant lessons, individually and/or collectively. Following the conclusion of the learning event we will consider any recommendations. Unfortunately, the family have not been available to participate which has had an impact on the progress of the learning event. We look forward to meeting with the family when they are available.”

Source location

Response from CQC
Page 4 · response
Published 7 May 2021

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 collaboration between social work, contract and review teams through scheduled monthly meetings.

Verbatim wording from the response

“• Social workers form a system with the social care contract and review team and associated processes. The senior commissioning officers and the locality social work managers work closely together and have scheduled monthly meetings;”

Source location

Response-from-Wonford-House-Hospital
Page 4 · response
Published 7 May 2021

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

Introduce a Local Authority-assigned social worker into the community forensic team to link social care and forensic services during transitions.

Verbatim wording from the response

“• Funding has been secured for a Local Authority assigned social worker to join the community forensic team from 1 April 2021. This social worker will provide a vital link between the social care teams and forensic services at the point of transition;”

Source location

Response-from-Wonford-House-Hospital
Page 4 · response
Published 7 May 2021

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

Undertake Root Cause Analysis investigations when incident thresholds are met, identifying causes, actions, responsibilities and deadlines.

Verbatim wording from the response

“Insofar as any incidents relating to any individuals for whom the Trust responsible, the Trust will consider whether the relevant thresholds are reached for it to undertake its own review by way of a Root Cause Analysis investigation. This entails a detailed review of the incident(s), identification of the root cause(s) and recommendations and actions to be taken. It also identifies who is responsible for undertaking those actions and by when. This enables the Trust to learn from incidents (which could include, but not limited to, the closure of a care home) and ensure actions are implemented.”

Source location

Response-from-Wonford-House-Hospital
Page 3 · response
Published 7 May 2021

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

Complete Care Act-compliant assessments documenting needs, strengths, wishes and networks to inform care plans and commissioning.

Verbatim wording from the response

“• There is a comprehensive, Care Act compliant assessment completed with the person. This documents the person’s needs, strengths, wishes and family and social networks. This is used in conjunction with health assessments to inform both care and support plans and commissioning;”

Source location

Response-from-Wonford-House-Hospital
Page 3 · response
Published 7 May 2021

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 referral did not meet Safeguarding Adult Review criteria because investigations found no crime, abuse, neglect, or related safeguarding failure.

Verbatim wording from the response

“Following review of all of the relevant information, it was agreed by the SAR subgroup that this referral did not meet the criteria for a SAR for the reasons stated below:”

Source location

Response-from-Plymouth-Safeguarding-Adults-Partnership
Page 2 · response
Published 7 May 2021

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

Internal review found no gaps or improvement areas in monitoring, inspection or enforcement methodology; existing actions were timely, justified and proportionate.

Verbatim wording from the response

“As part of the internal review undertaken in this case, CQC considered whether it revealed areas for improvement in CQC’s monitoring, inspection and/or enforcement methodology. We determined that the case did not reveal gaps or areas for improvement and that CQC’s actions were timely, justified and proportionate. In particular, partner agencies (Local Authority and Commissioners) made the necessary contingency arrangements to find residents living at Annette’s Care alternative homes; during this process the CQC worked closely with our partner agencies.”

Source location

Response from CQC
Page 4 · response
Published 7 May 2021

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 evidence was insufficient to establish provider-level failure causing avoidable harm or significant risk to the deceased.

Verbatim wording from the response

“As part of CQC methodology, CQC also undertook an initial assessment of the specific incident concerning Mr MacMartin to determine whether there were reasonable grounds to suspect that a criminal offence may have been committed by the provider Annette’s Care Limited under Regulations 12(1) and 22(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We determined there was insufficient evidence of provider level failure to provide safe care and treatment under Regulation 12(1) resulting in avoidable harm to Mr MacMartin or exposing him to a significant risk of such harm occurring.”

Source location

Response from CQC
Page 2 · response
Published 7 May 2021

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

Devon Partnership Trust was responsible for commissioning the deceased’s care and reviewing its ongoing quality and support.

Verbatim wording from the response

“Devon Partnership Trust (DPT) were the responsible Commissioner for Mr Glenn MacMartin’s care and support, and for the ongoing review of the quality of that care and support.”

Source location

Response from CQC
Page 4 · response
Published 7 May 2021

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

Partner agencies, including the local authority and commissioners, were responsible for arranging residents’ alternative homes after closure.

Verbatim wording from the response

“As part of the internal review undertaken in this case, CQC considered whether it revealed areas for improvement in CQC’s monitoring, inspection and/or enforcement methodology. We determined that the case did not reveal gaps or areas for improvement and that CQC’s actions were timely, justified and proportionate. In particular, partner agencies (Local Authority and Commissioners) made the necessary contingency arrangements to find residents living at Annette’s Care alternative homes; during this process the CQC worked closely with our partner agencies.”

Source location

Response from CQC
Page 4 · response
Published 7 May 2021

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 relevant Local Authority is responsible for determining whether safeguarding investigations are required and who should undertake them.

Verbatim wording from the response

“Where concerns about an individual’s care are raised with the Trust, whether by the care provider, family members, professionals or the individual themselves, the Trust is under a duty to consider whether a safeguarding referral needs to be made to the relevant Local Authority. It is then for the relevant Local Authority under section 42 Care Act 2014 to identify whether further investigations ought to be undertaken and if so by whom. This provides further safety netting in respect of any concerns which could be raised by or on behalf of the individual.”

Source location

Response-from-Wonford-House-Hospital
Page 3 · response
Published 7 May 2021

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 CQC is responsible for monitoring, reviewing and enforcing applicable regulatory requirements for care homes.

Verbatim wording from the response

“As above, it is otherwise for the CQC to monitor, review and if necessary enforce any of the relevant regulatory provisions of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”

Source location

Response-from-Wonford-House-Hospital
Page 3 · response
Published 7 May 2021

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