Andrew Nickolls

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.

Action should be taken

I would ask you please to consider what steps could be taken to ensure there is prompt exchange of information about an individual’s personal circumstances and where appropriate, should they be a vulnerable individual, for them to be provided support from a Safeguarding Adult team.

Your response

You are under a duty to respond to this report within 56 days of the date of this report namely, 12th August 2015. I, the Coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.

Copies and publication

I have sent a copy of my report to The Chief Coroner and to the following interested persons

The Chief Constable of Devon & Cornwall Constabulary

MP for Totnes and Chair of the Health Select

Committee

Secretary of State for Health

Family members

I am under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response to the Chief Coroner

I.M. ARROW

Dated 17th June 2015 Senior Coroner – Plymouth, Torbay & South Devon