Skip to main content

NHS Somerset Clinical Commissioning Group, Somerset Partnership NHS Foundation Trust, Taunton and Somerset NHS Foundation Trust, NHS England and Somerset County Council statement

This review by Professor Brian Toft was commissioned by NHS Somerset Clinical Commissioning Group (CCG), Somerset Partnership NHS Foundation Trust, and Taunton and Somerset NHS Foundation Trust to examine whether changes have been made to services since the death of Mr Andrew Prentice in July 2009. It is not an investigation into the health and social care services Mr Prentice received, although we know that sadly there were a number of involuntary failures in the processes, procedures and systems that provided his health and social care needs.

At the time of writing the review Professor Brian Toft was Principal of Risk Partnerships and Visiting Professor of Patient Safety at Brighton and Sussex Medical School.

Objectives of the review

The objectives of the review were to:

  • Identify opportunities to improve care across a range of health and social care services.
  • Review areas where service provision failed to meet Mr Prentice’s health and social care needs and form a view on whether these conditions continue today.
  • Use the findings to inform individual service providers and the wider care system of gaps in services and / or arrangements which should be prioritised for improvement
  • Review how complaints are responded to now in Somerset.

What the review found

Prof. Toft’s report found that:

  • Health and social care services have changed and evolved since 2009. For example he explains that, ”the government’s legislative reforms have created a sea change in the way homelessness is managed and the way in which social care is provided by local authorities”.
  • There have been some notable changes to the clinical services which Mr Prentice used, such as the provision of insulin and morphine pumps, patient’s not being discharged from the pain management service until they are ready, a structured education course for insulin dependent diabetes sufferers and a Home First service which speeds up some patients’ discharge from hospital.
  • Home First was introduced in Somerset in 2018 to support patients after they are discharged from hospital.

The report concludes that a person suffering from the same or a similar medical condition as Mr Prentice would today find a health and social care environment that is considerably different to the past, and one which has vastly improved.  The report also makes recommendations where further improvements can be made and these are being reviewed and actioned.

The response from health and social care

NHS Somerset CCG, Somerset Partnership NHS Foundation Trust and Taunton and Somerset NHS Foundation Trust said: “We wish to express our sympathy to Mrs Prentice for the loss of her son. We understand her frustration and feeling that health and social services let her son down.  We hope that this review and our commitment to take action where possible will bring her some comfort.

“In Somerset, health and social care agencies are working together more and more to ensure services are integrated – this is one of the central aims of the Fit for My Future programme.” 

NHS England South West has also received the report and acted on the recommendations.

Somerset County Council said:

“We understand the frustration this case caused and reiterate our sympathies to Mrs Prentice. There have been considerable improvements across the system since the period covered by this review, but more can always be done and we welcome the report and its recommendations which are being taken forward by all the agencies involved.”

Action plan of recommendations