“~ (1) The Devon Partnership trust acknowledged in inquest that the “locked door’ is still…”
Dated 25 Oct 2016, from the coroner for Exeter and Greater Devon. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 20 Dec 2016.
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; a reply may have been sent and not yet published.
- Report dated25 Oct 2016
- Deadline20 Dec 2016
- Published on judiciary.uk25 Oct 2016
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Devon Partnership NHS TrustNamed in the report as “Devon Partnership Trust” | Response publishedPublished on judiciary.uk in October 2016. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
~ (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. (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. (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.
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, 2016-0385
- Added to Minute Book
- 8 Oct 2026
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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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