Erika Francis

Dear Ms Archer, Re: Erika Francis — response to Regulation 28 Report to Prevent Future Deaths I write in my capacity as Chief Nursing Officer and Allied Health Professions Lead at Devon Partnership NHS Trust (the Trust) in response to your Regulation 28 Report to Prevent Future Deaths dated 12 August 2026. The Trust extends its sincere condolences to Erika Francis’s family and those affected by her death. We recognise the importance of the concerns identified through the inquest and accept that our previous domestic abuse training offer was not sufficiently detailed, consistently accessible or tailored to the needs of a specialist mental health provider, including the established association between domestic abuse, self-harm, suicide and homicide. Work to improve the Trust’s provision had commenced before the inquest. The Regulation 28 Report has reinforced the need to accelerate this work and ensure that the resulting programme is comprehensive, role-appropriate, applied in clinical practice and subject to formal assurance. We have considered each of the four concerns in your report. Our response below sets out the immediate action taken, the further work commissioned, and how implementation and effectiveness will be monitored. Actions recommended by the Coroner
• Devon Partnership NHS Trust staff had not received detailed training on domestic abuse and its significance for patients and service users experiencing domestic abuse.
• Although there appeared to be evidence that training in relation to domestic abuse was being developed or planned, it did not appear to be sufficiently comprehensive, readily accessible to all staff, or focused on the challenges of identifying domestic abuse in patients with mental ill health. Nor did it adequately address the established links between domestic abuse, homicide and suicide.
• Recent Domestic Homicide Reviews undertaken in Devon had identified shortcomings in professionals' understanding and

[Page 2] recognition of domestic abuse and had highlighted the importance of improved training and awareness across agencies.
• There remains a need for training to assist professionals in identifying the effects that domestic abuse may have on patients and service users with mental health conditions, including how domestic abuse may present, the barriers to disclosure, and the increased risks of self-harm and suicide associated with such experiences. Actions the Trust has taken and is planning to undertake in response to the Regulation 28 The Trust currently includes domestic abuse within its Safeguarding Adults and Safeguarding Children training. We acknowledge that this did not provide the depth, mental-health-specific focus or practical application required to address the concerns identified by the Coroner. The enhanced programme described below will therefore supplement, rather than simply restate, the existing safeguarding offer.
1. Immediate access to foundational learning Four accredited domestic abuse modules have been added to the Trust’s Develop learning platform and are available to staff. These NHS England e-Learning for Healthcare modules provide an interim foundational offer while the enhanced Trust programme is developed. They cover understanding domestic violence and abuse; identification; risk assessment; and safety planning and support for families.
2. Development of a mental-health-specific, role-based training programme The Head of Safeguarding is leading development of a tiered programme with support from the Integrated Care Board’s domestic abuse specialist lead, partner NHS organisations and specialist third-sector providers (Devon Domestic Abuse Alliance, FearFree, RISE and Devon Rape Crisis and Sexual Abuse Service). The proposed model comprises a concise introductory module for all staff and an enhanced face to face half-day or full-day programme for clinical and registered staff, prioritising staff who assess, plan or deliver care to people at greater risk to be affected by domestic abuse. The enhanced curriculum will include: recognising physical, psychological, sexual, economic, coercive and controlling abuse; barriers to disclosure and safe enquiry; trauma-informed responses; risks to children and other dependants; confidentiality, information sharing and safeguarding; use of local referral and multi-agency pathways; documentation; professional curiosity; risk assessment and safety planning; and the relationship between domestic abuse, deteriorating mental health, self-harm, suicide and homicide. It will also address how perpetrator behaviour and coercive control can affect assessment, engagement and care planning. The programme will align with the Domestic Abuse Act 2021 statutory guidance, national healthcare guidance on responding to domestic abuse, and current NHS England best practice on person-centred suicide safety assessment, formulation, management and planning. It will use case-based learning relevant to inpatient, community, crisis, perinatal, learning disability and older people’s mental health services.
3. Practice support, pathways and resources The Trust’s DAISY intranet contains a dedicated domestic abuse page with guidance, referral information and support resources. This is resource is being reviewed, updated and strengthened to include the association between

[Page 3] domestic abuse and suicide risk, prompts for safe and private enquiry, immediate safety and escalation advice, local specialist contacts, and clear expectations for recording, information sharing and follow-up. Existing clinical policies, assessment documentation and care-planning guidance will be reviewed to ensure that domestic abuse, coercive control and related suicide risk are considered consistently within assessment, formulation, safeguarding, safety planning and transition or discharge processes. Any required amendments will be completed through the Trust’s established policy governance arrangements. Key to this resource is guidance on how to access local domestic violence support
4. Delivery, governance and assurance Within four weeks of this response, the Head of Safeguarding will complete the workforce competency mapping and agree the learning outcomes, target groups, delivery method and implementation timetable with the ICB specialist lead. The enhanced programme will then be developed and quality-assured, with implementation commencing within six months of this response. If external dependencies affect these timescales, an interim risk-based briefing and facilitated learning offer will be provided to priority clinical services. Progress will be overseen through the Trust’s safeguarding governance arrangements and reported into the Trust Quality and Outcomes Committee. Assurance will include training assignment and completion by staff group and service, learner feedback and confidence measures, audit of the quality of enquiry, recording, referral and safety planning, and learning from incidents, safeguarding reviews, complaints and Domestic Homicide Reviews. The programme and implementation plan will be reviewed with people who have lived experience and specialist domestic abuse partners, with further improvement made in response to evaluation findings. The Trust is committed to ensuring that staff can recognise domestic abuse, respond safely and compassionately, and understand its potential contribution to self-harm and suicide risk. We consider that the actions above directly address the concerns raised in your report and provide a framework for sustained improvement and assurance. I hope this response provides the assurance requested. We would be pleased to provide further evidence of implementation or an update on progress if that would assist.