NHS Gloucestershire Clinical Commissioning Group

Health and care · Clinical commissioning group

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First report 27 Jun 2016•Latest report 2 Feb 2018

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from NHS Gloucestershire Clinical Commissioning Group linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Gloucestershire

    AI-generated summary

    Barbara Caroline Ellis · 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

    Barbara Caroline Ellis, who had significant physical and mental health difficulties and a history of suicide attempts, died after jumping from an overbridge on 4 April 2017; she was pronounced deceased on 6 April 2017. The report identified a cross-border care concern involving her GP and healthcare in Herefordshire and social care in Gloucestershire, which resulted in her being unable to access therapeutic services from either commission.

    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 Gloucestershire Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure access to therapeutic services across county commissioning boundaries

    Wider context from the report

    “The Cross border issue of care - whether patients can access services adequately when they have a GP in one County, and pay Council tax to another. In this case Mrs Ellis had a GP in Herefordshire, but paid Council Tax to Gloucestershire. This meant that her healthcare was being provided by Herefordshire Commissioners, and her social care from Gloucestershire Social Services. This result in her being unable to access therapeutic services from either commission. ”
    Open source report

  2. Gloucestershire

    AI-generated summary

    Anielka Agnes Grace Marie Jennings · 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

    Anielka Agnes Grace Marie Jennings, aged 17, was found hanging from a banister at home on 5 February 2015 and was pronounced deceased at 1510 hours. The principal concern was that, when numerous agencies care for a child transitioning to adult services, the absence of a lead or key professional can lead to communication breakdown between agencies.

    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 Gloucestershire Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of an identified lead professional for individuals receiving care from numerous agencies

    Wider context from the report

    “(1) When an individual is being cared for by numerous agencies, in particular when said individual is a child transitioning to adult services, there is no lead/ key professional identified, which can result in a breakdown of communication between the agencies. ”
    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

Data last updated 7 September 2026