Recipient

Anglian Community Enterprise (ACE) Community Interest Company

First report 16 Sep 2016•Latest report 16 Sep 2016

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Community interest company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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 Anglian Community Enterprise (ACE) Community Interest Company linked to the concerns in each report. Select any concern, action or position to view the source wording.

16 Sep2016
Essex
Concerns raised6
1. Failure to ensure appropriately senior staff make decisions
2. Lack of engagement of ward staff and ward manager
3. Over-reliance on agency staff
1. Failings in documentation
2. Lack of prompt response to patient deterioration
3. Serious failings in communication across shifts, with senior staff, and at multidisciplinary meetings
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Martha Ann Davies · 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

Martha Ann Davies, a 98-year-old woman, fell at home, underwent surgery for a fractured hip, was transferred for rehabilitation, suffered a further fall, and died in hospital on 29 November 2015. The report identified concerns including communication failings, reliance on agency and junior staff, delayed response to deterioration, lack of engagement by ward staff and management, and documentation failings; the inquest concluded that she did not receive adequate care and appropriate treatment at Clacton District Hospital, which may have contributed to her death.

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 Anglian Community Enterprise (ACE) Community Interest Company; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure appropriately senior staff make decisions
Wider context from the report
“(2) Over reliance upon agency staff and on junior staff to make decisions ”
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 Anglian Community Enterprise (ACE) Community Interest Company; that does not assign responsibility.
PFD Monitor interpretation
Lack of engagement of ward staff and ward manager
Wider context from the report
“(4) Lack of engagement of ward staff and ward manager ”
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 Anglian Community Enterprise (ACE) Community Interest Company; that does not assign responsibility.
PFD Monitor interpretation
Over-reliance on agency staff
Wider context from the report
“(2) Over reliance upon agency staff and on junior staff to make decisions ”
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 Anglian Community Enterprise (ACE) Community Interest Company; that does not assign responsibility.
PFD Monitor interpretation
Failings in documentation
Wider context from the report
“(5) Failings in the documentation ”
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 Anglian Community Enterprise (ACE) Community Interest Company; that does not assign responsibility.
PFD Monitor interpretation
Lack of prompt response to patient deterioration
Wider context from the report
“(3) Lack of prompt response to the patient’s deteriorating state. ”
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 Anglian Community Enterprise (ACE) Community Interest Company; that does not assign responsibility.
PFD Monitor interpretation
Serious failings in communication across shifts, with senior staff, and at multidisciplinary meetings
Wider context from the report
“(1) Serious failings in communication between shifts, with senior staff, and at multi-disciplinary meetings ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised6

Failure to ensure appropriately senior staff make decisions

Lack of engagement of ward staff and ward manager

Over-reliance on agency staff

Failings in documentation

Lack of prompt response to patient deterioration

Serious failings in communication across shifts, with senior staff, and at multidisciplinary meetings