Delayed and ineffective incident investigations by managers
Care Quality Commission received 2 coroners' reports about this hazard between 10 Jan 2014 and 11 Oct 2023.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from Care Quality Commission was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“failure of the nursing home managers to undertake an effective investigation into this incident and to take action to prevent repetition”
Original on judiciary.uk ↗ No published response from Care Quality Commission was found for this report.
- 9 years 9 months laterClosely relatedConfidence 0.90 · higha different coroner
“The serious incident investigation remained unallocated and with no timeframe for completion for over 7 months”
Original on judiciary.uk ↗ Repeated from the earlier report:incidentinvestigation
Care Quality Commission responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Care Quality Commission
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.
2014 → 2023Sarah Holmes9 years 9 months after Mary Waldron · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight failures in conducting timely and effective investigations of incidents. The earlier case concerns nursing home managers not investigating properly; the later case concerns a trust's serious incident investigation left unallocated and without a timeframe.
Mary Waldron · 10 Jan 2014
“failure of the nursing home managers to undertake an effective investigation into this incident and to take action to prevent repetition”
Original on judiciary.uk ↗ Sarah Holmes · 11 Oct 2023
“The serious incident investigation remained unallocated and with no timeframe for completion for over 7 months”
Original on judiciary.uk ↗
No published response from Care Quality Commission was found for this report.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
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 Care Quality Commission 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 |
|---|---|---|---|---|
| 2014 → 2023 | 0.70 | 0.18 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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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.