Jessie... where to start? The PFD report itself is addressed to the DHSC, and covers "the total inadequate level of community provision for the care and treatment of those with suffering with Autism. This is a national problem and sadly leads to many experiencing unnecessary admissions to inpatient mental health facilities and also A&E attendances."

A lot of further detail emerged during the inquest, including failures to communicate both within and across the prrofessional teams caring for Jessie; failure to talk to (and listen to) Jessie and her parents; and a lack of professional/clinical curiosity which meant staff were not identifying and probing her underlying needs.

Whilst I've been fortunate to find this further detail, it suggests that there may be more PFD reports providing evidence of these and perhaps other problems, and that the 228 reports I've identified here may only offer a partial view.