“The pertinent circumstances of Andrew’s death were that he was living in Dartmouth”
Dated 17 Jun 2015, from the coroner for Plymouth, Torbay and South Devon. Sent to 5 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 12 Aug 2015. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated17 Jun 2015
- Deadline12 Aug 2015
- Published on judiciary.uk17 Jun 2015
- Today28 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS Northern, Eastern and Western Devon Clinical Commissioning GroupNamed in the report as “Northern Eastern and Western Devon Clinical Commissioning Group” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 12 Aug 2015. A reply may have been sent and not yet published. |
| NHS South Devon and Torbay Clinical Commissioning GroupNamed in the report as “Torbay and South Devon Clinical Commissioning Group” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 12 Aug 2015. A reply may have been sent and not yet published. |
| Plymouth City Council | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 12 Aug 2015. A reply may have been sent and not yet published. |
| Devon County Council | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 12 Aug 2015. A reply may have been sent and not yet published. |
| Torbay Council | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 12 Aug 2015. A reply may have been sent and not yet published. |
The coroner’s concerns
The pertinent circumstances of Andrew’s death were that he was living in Dartmouth. He was registered with a GP in Plymouth. He attended Torbay Hospital on numerous occasions. Following his death the Torbay & South Devon Clinical Commissioning Group conducted an investigation into the circumstances of his death. This investigation was carried out by A copy of her report with substantial recommendations has been shared with the NEW Clinical Commissioning Group and the Torbay & South Devon Clinical Commissioning Group. I also understand copies are to be shared with The Chief Executive of: Plymouth City Council, Devon County Council and Torbay Council. The principal learning point is to be that there is an advantage in a patient being looked after by a primary carer (i.e. a GP) within the Clinical Commissioning Group. If this is not the case, then it is imperative that there is clear information sharing, particularly where there is a vulnerable adult and there is a possibility they are neglecting themselves. May I observe there may be an advantage in sharing information with Devon & Cornwall Police who clearly keep an index of vulnerable individuals as these individuals may come to the Forces notice through other routes.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2015-0230
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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