Nicholas Dymond

Alison Longhorn 
HM Area Coroner for Exeter & Greater 
Devon 
Room G85 
County Hall 
Exeter 
EX2 4QD 

Trust Headquarters 
Wonford House 
Dryden Road 
Exeter 
EX2 9AF 

Date: 19th  February 2024 

Dear Ms Longhorn, 

Re. Nicholas Dymond – Regulation 28 Report 

I write in my capacity as Executive Chief Nursing Officer & Allied Professions Lead for Devon 
Partnership NHS Trust (“the Trust”) in response to your Regulation 28 report dated 21 
December 2023. If I can first of all pass on my condolences to Mr Dymond’s family. 

In your report you highlighted two areas of concern, in respect of which I respond below: 

The inquest heard that independent doctors did not have access to the CareNotes and 
relied upon printed copies of extracts from the notes which the AMHP considered 
pertinent to the Mental Health Act Assessment. Training is now available for 
independent s.12 doctors which, once completed, allows them access to CareNotes, 
but this training is not a mandated condition of their inclusion on the list of approved 
s.12 doctors. There remains a risk that, should a Trust doctor not be available to 
conduct the assessment, an independent doctor with no access to the patient’s records 
would be called upon to conduct an assessment. 

The Trust has recently moved to a new electronic patient records system – Systm1 - which is 
widely used in Devon across the healthcare system, particularly within primary care, which 
means that most doctors are proficient in its use, although training is still offered if required.  It 
is worth adding that the approval of s.12 MHA doctors is not a Trust responsibility, nor is it 
specific to our Trust. The Trust is not therefore able to make training a mandatory requirement 
of their inclusion on the list of doctors approved under s.12 MHA.  In the South West, the 
approval of s12 doctors is undertaken by Winterhead Limited. Winterhead acts on behalf of the 
Secretary of State for Health to administer the approval of clinicians in the South of England to 
act as Approved Clinicians (AC) and doctors approved under section 12(2) of the Mental 
Health Act 1983. 

The Trust endeavours to ensure that assessments under the Mental Health Act 1983 (“the 
MHA”) with no doctor from the Trust take place only in exceptional circumstances. As 

 highlighted in her statement dated 19 September 2023, the Trust’s duty rota ensures 
that there is one s.12 MHA approved Trust psychiatrist ‘on call’ in each area, to attend MHA 
assessments. 

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 As the Systm1 roll out only began in November 2023, we do not yet have the data to confirm 
the number of Trust Doctors who have completed assessments but the expectation is that the 
vast majority, if not all, of MHA assessments continue to involve at least one Trust psychiatrist. 

However, it should be noted that the assessment is undertaken by a team who assess 
together, so in the rare event that a medical member of the team did not have access steps 
would be taken by the other assessors to facilitate access to the notes prior to the 
assessment. 

The “Devon Shared Care Record” is also now being implemented. This will facilitate cross 
organisational access to clinical care records and so further improve availability of relevant 
information to clinicians. 

Several witnesses illustrated a lack of understanding of the concept of both a voluntary 
admission where a patient has undergone a Mental Health Act Assessment and of the 
‘least restrictive option’. The opportunity for a patient to be admitted voluntarily for 
further assessment and treatment may therefore be missed. 

The majority of Trust services are delivered outside hospital settings.  Informal admission to an 
acute psychiatric ward would happen when risk and treatment thresholds are met but the 
person is capacitous and consenting to admission. 

The Mental Health Act is explicit in laying out the primacy of the principles of least restriction 
pointing to admission only where treatment is not available outside of the hospital setting and 
there are stringent legal criteria governing compulsory admission 

Since 2015 the Trust has taken steps to put additional measures in place to support people 
safety outside of the inpatient setting. 

To that end, the Trust has opened Redhills Crisis house in Exeter. Redhills is not a registered 
hospital setting but offers supported and crisis admission with 24 hour Trust staff on an 
elective basis. On occasion people are moved from Redhills to a treatment ward, but more 
usually it is a short term, empowering and stabilising intervention designed to take people past 
the immediate point of risk to self. 

Repeat admissions to Redhills are accepted when people destabilise. Redhills accommodates 
people from Exeter, East and South, while we have contracted a number of supported beds for 
use as Step up from the community and /or step down from the wards in North Devon - these 
spaces are clinically supported by our home treatment teams and are solely accessible to 
informal patients. 

The Trust has also opened in the interim period 18 psychiatric rehabilitation beds across 
Devon, which support people with long term psychosis. This further increases our inpatient 
capacity.  Our Home Treatment Team (“HTT”) has also been redesigned since 2015 with the 
assessment function now sitting within the First Response Team and HTT delivering intensive 
support as an alternative to admission. The First Response Team is a service initially 
accessed by telephone and which undertakes triage, assessment, face to face contacts and 
onwards referrals for people in crisis. 

 highlighted in her statement dated 19 September 2023, in Mr Dymond’s case, 

As 
neither of the assessing doctors was a psychiatrist. As described above, whilst not a legal 
requirement, the Trust’s practice now is to make its best endeavours to ensure that at least 
one of the assessing doctors is a psychiatrist who works within the Trust. 

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 Psychiatrists are experts at assessing risk and Trust psychiatrists assess developing risks in 
patients every day, and will consider treatment and care pathway options, including possible 
voluntary admissions and the least restrictive principle. It should be remembered though that 
treatment at home in the community can be the most appropriate and least restrictive option in 
many cases. 

 has highlighted that the MHA assessments are subject to a robust audit process 

by both MHA office and AMHP peer review.  AMHP managers discuss any matters and issues 
arising with individuals within the supervision process.  It is a legal requirement for AMHPs to 
undertake statutory training in each year, failure to do so results in their approval and authority 
to practice being removed. This training ensures that legal knowledge is refreshed and current 
and also covers best practice and current challenges. 

I trust that the above assists. 

Yours sincerely 

Executive Chief Nursing Officer & Allied Professions Lead 

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