Missing falls prevention equipment in resident care
Care Quality Commission received 2 coroners' reports about this hazard between 14 May 2018 and 10 Jul 2025.
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 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The care home may not have some of the equipment that they require for patients such as Mrs [name redacted] e.g. a bed sensor mat.”
Original on judiciary.uk ↗ Care Quality Commission responded.Response (PDF) ↗
- 7 years 2 months later
Raised again · 1st time
Patricia Heaviside↗
10 Jul 2025 · Rebecca Sutton · County Durham and Darlington
Identical hazardConfidence 0.90 · higha different coroner“Despite the social worker expressing concern about the lack of falls prevention equipment on 27 September 2024, no falls equipment was put in place prior to the Deceased's fall on 4 October 2024.”
Original on judiciary.uk ↗ Care Quality Commission responded.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.
2018 → 2025Patricia Heaviside7 years 2 months after Gladys Rich · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that necessary falls‑prevention equipment (e.g., a bed sensor mat) was not provided to residents despite identified need.
Gladys Rich · 14 May 2018
“The care home may not have some of the equipment that they require for patients such as Mrs [name redacted] e.g. a bed sensor mat.”
Original on judiciary.uk ↗ Patricia Heaviside · 10 Jul 2025
“Despite the social worker expressing concern about the lack of falls prevention equipment on 27 September 2024, no falls equipment was put in place prior to the Deceased's fall on 4 October 2024.”
Original on judiciary.uk ↗
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 |
|---|---|---|---|---|
| 2018 → 2025 | 0.77 | 0.09 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
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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.