Inadequate staff knowledge of pressure sore prevention and equipment use
Department of Health and Social Care received 2 coroners' reports about this hazard between 23 Jul 2015 and 17 Aug 2021.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“Staff working on mental health wards dealing with elderly patients must have a clear understanding of basic medical care in particular how pressure sores occur and what steps are required to address those at high risk.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“was to write to you again in March 2016 to confirm that all future actions have indeed been delivered.”
Stated timescale: March 2016
- 6 years 1 month laterClosely relatedConfidence 0.85 · higha different coroner
“once Mr [name redacted] sacral sore had occurred, due to staff inexperience and lack of training, the equipment provided to reduce the further development of his sacral sore was either not utilised, or if utilised sometimes used incorrectly.”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗
- All reports to Department of Health and Social Care
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2015 → 2021Roland Stannard6 years 1 month after Doreen England · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight that insufficient staff training leads to inadequate management of pressure ulcers/sores. The earlier report stresses lack of knowledge about sore formation and prevention, while the later report notes that inexperience results in misuse of preventive equipment.
Doreen England · 23 Jul 2015
“Staff working on mental health wards dealing with elderly patients must have a clear understanding of basic medical care in particular how pressure sores occur and what steps are required to address those at high risk.”
Original on judiciary.uk ↗ Roland Stannard · 17 Aug 2021
“once Mr [name redacted] sacral sore had occurred, due to staff inexperience and lack of training, the equipment provided to reduce the further development of his sacral sore was either not utilised, or if utilised sometimes used incorrectly.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“was to write to you again in March 2016 to confirm that all future actions have indeed been delivered.”
Stated action · timescale: March 2016
“was to write to you again in March 2016 to confirm that all future actions have indeed been delivered.”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Department of Health and Social Care at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2015 → 2021 | 0.79 | 0.20 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Department of Health and Social Care
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.