2 Apr 2026 Peter PETTITT · Prevention of Future Deaths report Suffolk
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Concerns raised 7 Lack of formal assured training arrangements for commissioned care View source Failure to raise medication non-compliance concerns with relevant healthcare and commissioning functions View source Inadequate support for medication management View source Inadequate catheter management support View source Inadequate recording of care attendances and actions taken View source Inadequate management of commissioned care services View source Inadequate assurance of commissioned care services View source See 4 more concerns
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Peter PETTITT · 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
Peter PETTITT, aged 86, died on 11 September 2023 after developing sepsis due to bronchopneumonia and acute pyelonephritis. The report raised concerns about inadequate care records, gaps in medication and catheter support, and insufficiently assured training and management arrangements for the commissioned care provided to him.
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 Multi-Care Community Services Suffolk; that does not assign responsibility.
PFD Monitor interpretation Lack of formal assured training arrangements for commissioned care
Wider context from the report “Training material and records provided to the Court suggested that no formal, assured training arrangements were in place to deliver the commissioned care to Mr. PETTITT. Evidence of subsequent actions following Mr. PETTITT’s death provided no confidence to the Court that inadequacies in training, assurance and management identified at the time of Mr. PETTITT’s death have subsequently been addressed.
” 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 Multi-Care Community Services Suffolk; that does not assign responsibility.
PFD Monitor interpretation Failure to raise medication non-compliance concerns with relevant healthcare and commissioning functions
Wider context from the report “In addition to poor record keeping, evidence heard during the Inquest raised concerns as to the adequacy of the support provided to Mr. PETTITT in the management of his medication. Stockpiles of medication were found at the residence clearly reflecting a lack of compliance by Mr. PETTITT in his medication regimen; support to Mr. PETTITT in medication management was a service Multi-Care Community Services Suffolk were commissioned to provide. No formal concern in relation to non-compliance with medication was raised by Multi-Care Community Services Suffolk with either the commissioning authority (Suffolk County Council), or Mr. PETTITT’s General Practice.
” 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 Multi-Care Community Services Suffolk; that does not assign responsibility.
PFD Monitor interpretation Inadequate support for medication management
Wider context from the report “In addition to poor record keeping, evidence heard during the Inquest raised concerns as to the adequacy of the support provided to Mr. PETTITT in the management of his medication . Stockpiles of medication were found at the residence clearly reflecting a lack of compliance by Mr. PETTITT in his medication regimen; support to Mr. PETTITT in medication management was a service Multi-Care Community Services Suffolk were commissioned to provide . No formal concern in relation to non-compliance with medication was raised by Multi-Care Community Services Suffolk with either the commissioning authority (Suffolk County Council), or Mr. PETTITT’s General Practice.
” 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 Multi-Care Community Services Suffolk; that does not assign responsibility.
PFD Monitor interpretation Inadequate catheter management support
Wider context from the report “Mr. PETTITT’s catheter management, both in terms of day-time changing and support to fitting of a night time catheter, were part of the services Multi-Care Community Services Suffolk were commissioned to provide. The Inquest heard evidence that catheter management for Mr. PETTITT was poor , with periods of days, possibly longer, where there was an absence of catheter support provided to Mr. PETTITT . It is possible that Mr. Pettit did not receive support in relation to his night-time catheter changes for several months .
” 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 Multi-Care Community Services Suffolk; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of care attendances and actions taken
Wider context from the report “Record keeping relating to the Suffolk County Council commissioned care provided to Mr. PETTITT was found to be inadequate, with significant gaps in records relating to frequency of attendances and details of actions taken during any attendance. The effect of these gaps in the records meant that there was no evidence carers had attended, nor undertaken commissioned care support actions for Mr. PETTITT , including assistance with medication and catheter management for periods of time extending up to several days.
” 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 Multi-Care Community Services Suffolk; that does not assign responsibility.
PFD Monitor interpretation Inadequate management of commissioned care services
Wider context from the report “Training material and records provided to the Court suggested that no formal, assured training arrangements were in place to deliver the commissioned care to Mr. PETTITT. Evidence of subsequent actions following Mr. PETTITT’s death provided no confidence to the Court that inadequacies in training, assurance and management identified at the time of Mr. PETTITT’s death have subsequently been addressed .
” 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 Multi-Care Community Services Suffolk; that does not assign responsibility.
PFD Monitor interpretation Inadequate assurance of commissioned care services
Wider context from the report “Training material and records provided to the Court suggested that no formal, assured training arrangements were in place to deliver the commissioned care to Mr. PETTITT. Evidence of subsequent actions following Mr. PETTITT’s death provided no confidence to the Court that inadequacies in training, assurance and management identified at the time of Mr. PETTITT’s death have subsequently been addressed .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations