“A root cause analysis investigation was undertaken by the Devon Partnership Trust and…”
Dated 19 Dec 2017, 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
Dates unclearOrganisations 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.
The date on the report comes after the day judiciary.uk put it online, so we can’t work out when replies were due.
- Report dated19 Dec 2017
- Published on judiciary.uk17 Dec 2017
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Responses from each recipient
| Sent to | Response |
|---|---|
| Devon Partnership NHS TrustNamed in the report as “Devon Partnership Trust” | Dates unclearNo response published on judiciary.uk. The date on the report comes after the day judiciary.uk put it online, so we can’t work out when replies were due. |
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) A root cause analysis investigation was undertaken by the Devon Partnership Trust and that report was finalised on the 8" September 2017. The report contained a number of identified lessons learned and recommendations, ten in total (see attached annexe), applicable to different teams within Devon Partnership Trust. it was unclear at the Inquest as to whether or not these recommendations have been considered and acted upon by the teams to which they were directed particularly where clients have talked of suicidal ideation and identified the means with which to bring about their death. in my opinion action should be taken to prevent future deaths and | believe you and your organisation has to take such action to confirm the recommendations in the root cause analysis report File No: 2017/10523 NON ANON RCA JHNS 18.9.17 — having been considered and implemented. (2) In addition where an individual has indicated an intent to cause themselves harm and have advised clinicians they have access to the means to cause that harm then protective factors should be put in place to help reduce the risk of the individual harming fhemselves in the way they have indicated or otherwise.
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
- Added to Minute Book
- 8 Oct 2026
- Reuse
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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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