Inadequate window restrictor strength in care settings
Care Quality Commission received 2 coroners' reports about this hazard between 1 Oct 2021 and 21 Jun 2024.
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.
“I was informed that CQC did not routinely check window restrictors on inspections.”
Original on judiciary.uk ↗ Care Quality Commission responded, stating 1 specific action.Response (PDF) ↗
“We will check at our next inspection that these changes have been embedded at St John's Nursing Home and that these were effectively minimising risks where these had been identified.”
Stated timescale: next inspection
- 2 years 9 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“it is suggested that window restrictors (and their fixings) are capable of withstanding push forces of at least 850N”
Original on judiciary.uk ↗ Repeated from the earlier report:windowrestrictors
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.
2021 → 2024Terrence Taylor2 years 9 months after Stephen Verrall · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports concern the adequacy of window restrictors in care settings to prevent residents from falling or exiting unsafely. The earlier report highlights a lack of routine checks by the regulator, while the later report points out that existing standards may be insufficient and calls for stronger restrictors and better guidance.
Stephen Verrall · 1 Oct 2021
“I was informed that CQC did not routinely check window restrictors on inspections.”
Original on judiciary.uk ↗ Terrence Taylor · 21 Jun 2024
“it is suggested that window restrictors (and their fixings) are capable of withstanding push forces of at least 850N”
Original on judiciary.uk ↗
Stated action · timescale: next inspection
“We will check at our next inspection that these changes have been embedded at St John's Nursing Home and that these were effectively minimising risks where these had been identified.”
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 |
|---|---|---|---|---|
| 2021 → 2024 | 0.70 | 0.26 | Closely related · 0.80 | 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.