Recipient

NHS Bristol Clinical Commissioning Group

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First report 20 Aug 2013•Latest report 20 Aug 2013

Recipient record

Reports, concerns and published responses

Health and care · Clinical commissioning group. 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 NHS Bristol Clinical Commissioning Group linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Avon

    AI-generated summary

    Ann Margaret SPEARING · 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

    Ann Margaret SPEARING had a history of learning difficulties, bereavement and dependency issues and lived in assisted accommodation. She was reviewed by mental health, hospital and eating-disorder services but was not considered to have a qualifying mental illness, medical condition or eating disorder. She starved herself over many months and died of pneumonia and malnutrition, with self-neglect contributing in the context of bereavement, a move to a new home, anxiety and dependence issues. The principal concern was that organisational eligibility criteria excluded her from effective care, leaving her passed between agencies without positive intervention.

    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 NHS Bristol Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of funding provision for such cases

    Wider context from the report

    “The concerns are that despite the involvement of all the relevant organisations this lady was able to precipitate her death by starving herself over a period of many months leading her GP to predict her death some months in advance. It appears that each of the relevant organisations had drawn their criteria in such a way as to exclude this lady from their care. She was always someone else's problem. There needs to be some method of providing funding in such cases rather than spending time and money passing the person from one agency to another without any positive curative action being taken. ”
    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 NHS Bristol Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of relevant organisations to provide care for people excluded by their eligibility criteria

    Wider context from the report

    “The concerns are that despite the involvement of all the relevant organisations this lady was able to precipitate her death by starving herself over a period of many months leading her GP to predict her death some months in advance. It appears that each of the relevant organisations had drawn their criteria in such a way as to exclude this lady from their care. She was always someone else's problem. There needs to be some method of providing funding in such cases rather than spending time and money passing the person from one agency to another without any positive curative action being taken. ”
    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