Inadequate repositioning and monitoring of at-risk patients
Care Quality Commission received 2 coroners' reports about this hazard between 20 Aug 2013 and 19 Dec 2025.
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.
“Infected pressure sores may have been a cause of death and they were unusual in extent and severity.”
Original on judiciary.uk ↗ No published response from Care Quality Commission was found for this report.
- 12 years 4 months laterIdentical hazardConfidence 0.90 · higha different coroner
“The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff.”
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.
2013 → 2025Ramona Harbott12 years 4 months after Mohammed Chaudhury · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports describe severe pressure ulcers resulting from inadequate repositioning and monitoring of at‑risk patients.
Mohammed Chaudhury · 20 Aug 2013
“Infected pressure sores may have been a cause of death and they were unusual in extent and severity.”
Original on judiciary.uk ↗ Ramona Harbott · 19 Dec 2025
“The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff.”
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.
- 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 |
|---|---|---|---|---|
| 2013 → 2025 | 0.76 | 0.18 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Care Quality Commission
- Inaccurate and inconsistent care plan entries and record keeping10 reports · 2017–2026
- Ambulance handover delays at hospitals reduce availability3 reports · 2015–2026
- Non‑compliance with care plans and insufficient incident review5 reports · 2016–2026
- Missing falls prevention equipment in resident care2 reports · 2018–2025
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.