Recipient

PJ Care Limited

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First report 14 May 2018•Latest report 14 May 2018

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Multi-service care 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 PJ Care Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Milton Keynes

    AI-generated summary

    Philip David Ashton · 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

    Philip David Ashton, a resident of Mallard House, was administered warfarin in error on 13, 14 and 15 October 2017. He was found bleeding from an arteriovenous graft on 17 October, and the report raised concerns about the medication error, the lack of an emergency response and the unavailability of his medical information to ambulance staff; he later died in 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 PJ Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of staff to deal effectively with emergency situations

    Wider context from the report

    “(2) The staff were not able to deal with an emergency situation. ”
    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 PJ Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of the deceased's notes to ambulance staff

    Wider context from the report

    “(3) The ambulance staff were not given any information about the deceased as to his medical history or medication. The notes relating to the deceased should have been available to them. ”
    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 PJ Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to administer anticoagulation medication correctly

    Wider context from the report

    “(1) That warfarin was administered to the deceased in error and the home should review their medication procedures and put in place a robust system for the administration of anti coagulation medication ”
    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 PJ Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide ambulance staff with medical history and medication information

    Wider context from the report

    “(3) The ambulance staff were not given any information about the deceased as to his medical history or medication. The notes relating to the deceased should have been available to them. ”
    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