Recipient

Achieve Together Limited

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First report 28 Jul 2016•Latest report 28 Jul 2016

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Supported living provider. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Achieve Together Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Manchester City

    AI-generated summary

    Leslie Johnson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Leslie Johnson, who required supported care and had a swallowing assessment recommending a soft diet and supervision, died in hospital after being left unsupervised while eating an egg mayonnaise sandwich. A post-mortem examination found that he died from acute aspiration of food. Concerns included failures to assess or recognise his lack of mental capacity and failures to communicate his care plan and swallowing requirements between community carers and the hospital.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Achieve Together Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide or obtain up-to-date mental health and care-plan information on hospital admission

    Wider context from the report

    “3. Details of his mental health condition and in particular his care plan did not accompany him and/or were not supplied by his carers or his care co-ordinator to the hospital, but nor did the hospital check or request information from those looking after him in the community. The concern is that in this case, the deceased’s death was avoidable and had there been appropriate communication between all those looking after him, steps would have been taken to ensure his oral diet complied with his current SALT assessment pending a review. It is suggested that the Hospital Trust, the Mental Health Trust and any caring organisation (whether that be a charity or a private organisation) should have policies and protocols which are applied to ensure that up to date information is provided upon admission to or discharge from hospital. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Achieve Together Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consider DoLS authorisation in the community

    Wider context from the report

    “1. Although it is appreciated that the events in question occurred later in 2014 following the Cheshire West case, it is a matter of concern that in the community, no formal mental capacity assessment was undertaken and no consideration of a DoLS authorisation was undertaken. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Achieve Together Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to undertake formal mental capacity assessments in the community

    Wider context from the report

    “1. Although it is appreciated that the events in question occurred later in 2014 following the Cheshire West case, it is a matter of concern that in the community, no formal mental capacity assessment was undertaken and no consideration of a DoLS authorisation was undertaken. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Achieve Together Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to formally assess and recognise mental capacity on hospital admission

    Wider context from the report

    “2. Consequently, upon his admission to hospital, it was not recognised that he lacked mental capacity. There was no formal assessment and he was treated as an ordinary patient. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026