The Manor Clinic

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First report 7 Jun 2025•Latest report 7 Jun 2025

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
1

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 The Manor Clinic linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. North East Kent

    AI-generated summary

    Mrs Ann Caldicott · 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

    Mrs Ann Caldicott had a long-standing history of weight loss, anaemia, declining renal function and frailty, and died in hospital on 21 February 2024 after a urinary catheter insertion caused a bladder perforation. The report identifies concerns that her malnutrition and declining frailty were not adequately investigated or treated, leaving her too physiologically frail for potentially lifesaving treatment. It also raises concerns that relevant internal investigations and reviews did not take place.

    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 The Manor Clinic; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct internal investigations for learning

    Wider context from the report

    “2. Ann’s marked Anemia and poor nutritional state meant that she was not suitable for potentially lifesaving treatment when it became necessary. 3. No internal investigations were conducted by Ann’s GP or by the East Kent Hospitals NHS Foundation Trust to establish if lessons could be learned as a result of the circumstances of Ann’s Death. 4. The Court was informed that there had been an SJR (of which I had not previously been notified) following Ann’s death. The Dr providing evidence was to raise a Datix in relation to Ann’s previous attendances and failed discharges. At the resumed inquest the Court were informed these investigations had not taken place and were not to take place. 5. No consideration was given prior to Ann’s final admission and some 18 months after the onset of symptoms of vomiting and chronic weightless, of support for Ann’s nutritional status. 6. If Ann had been in a better nutritional state on her final admission to the Kent and Canterbury, then she would have been well enough to undergo lifesaving treatment following the bladder perforation. ”
    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 The Manor Clinic; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consider support for nutritional status

    Wider context from the report

    “2. Ann’s marked Anemia and poor nutritional state meant that she was not suitable for potentially lifesaving treatment when it became necessary. 3. No internal investigations were conducted by Ann’s GP or by the East Kent Hospitals NHS Foundation Trust to establish if lessons could be learned as a result of the circumstances of Ann’s Death. 4. The Court was informed that there had been an SJR (of which I had not previously been notified) following Ann’s death. The Dr providing evidence was to raise a Datix in relation to Ann’s previous attendances and failed discharges. At the resumed inquest the Court were informed these investigations had not taken place and were not to take place. 5. No consideration was given prior to Ann’s final admission and some 18 months after the onset of symptoms of vomiting and chronic weightless, of support for Ann’s nutritional status. 6. If Ann had been in a better nutritional state on her final admission to the Kent and Canterbury, then she would have been well enough to undergo lifesaving treatment following the bladder perforation. ”
    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 The Manor Clinic; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to investigate malnutrition and declining frailty

    Wider context from the report

    “1. Ann’s malnutrition and declining frailty were not investigated despite continued requests by Ann and her family to primary and secondary care settings. ”
    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 The Manor Clinic; that does not assign responsibility.

    PFD Monitor interpretation

    Poor nutritional state compromising suitability for lifesaving treatment

    Wider context from the report

    “2. Ann’s marked Anemia and poor nutritional state meant that she was not suitable for potentially lifesaving treatment when it became necessary. 3. No internal investigations were conducted by Ann’s GP or by the East Kent Hospitals NHS Foundation Trust to establish if lessons could be learned as a result of the circumstances of Ann’s Death. 4. The Court was informed that there had been an SJR (of which I had not previously been notified) following Ann’s death. The Dr providing evidence was to raise a Datix in relation to Ann’s previous attendances and failed discharges. At the resumed inquest the Court were informed these investigations had not taken place and were not to take place. 5. No consideration was given prior to Ann’s final admission and some 18 months after the onset of symptoms of vomiting and chronic weightless, of support for Ann’s nutritional status. 6. If Ann had been in a better nutritional state on her final admission to the Kent and Canterbury, then she would have been well enough to undergo lifesaving treatment following the bladder perforation. ”
    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