Dear Mr ( OX Ref:_Regulation 28 report to Prevent Future Deaths: Patient: Mr_Michael John_Valentine dob: 26.03.69 dod:_16.09.154 Thank Yo ! for your letter dated 3rd February 2016 addressed to Dr Hall. Dr Hall has passed your correspondence to me as the person best suited in the Practice to arrange the actions to be taken. An audit of post was taken on 23/2/16. 235 pieces of correspondence were referred on this 216 were distributed to the GPs working that GP does not routinely work that day and 19 pieces of correspondence were reviewed by the Doctor for urgency and 18 pieces of correspondence were deemed safe to leave for the doctors return one later A re-audi: was undertaken on 22/3/16. 209 pieces of correspondence were received 0n this 175 were Jistributed to the GPs working that 2 GPs were not working that 100% (34) of their correspondence was reviewed by the Duty Doctor for safety and 33 pieces of correspondence were deemed safe to wait for the GPs to return to review. On balance we are happy that we now have robust procedures for reviewing post and electronic communication within the Practice t0 our patients safe We met Iith our Secon Care Psychiatry colleagues on 18h March 2016 and discussed the rejection , rocess as well as carrying out a Significant Event analysis on Mr Valentine'$ death. enclose copy of the minutes and outcomes of that meeting:

Dear Sir am writing in response to your letter sent to our Medical Director In order to progress this we have had meeting with Senior Management of Livewell South West and myself as Clinical Director of Adult Mental Health and have reviewed the case have reviewed the process of urgent referrals: We note that Knowle House Surgery considered this as part of their Significant Event Process and we met with the practice on Friday 18h March. We understand that the practice will forward a record of the meeting to you. Our actions are as follow: In future any staff that reject an urgent referral will be contacting the referrer direct to confirm the outcome of their assessment of the referral, 2 We will also continue with our usual practice that Devon Referral Support Services (DRSS) will notify the referrer; in writing; of any referrals not accepted. 3 We will be seeking advice from the Local Medical Committee to ask how learning can be shared throughout the Primary Care arena and Secondary Care arena. On a matter of accuracy, the request for an assessment from the North Community Mental Health Team was a request for a Mental Health assessment, not a Mental Health Act assessment; which would be a different process With all best wishes