Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of connectivity between agency information systems
The earlier warning
Charles Grainger · 12 May 2018 · Rachel Syed, Derby and Derbyshire
“Relevant information regarding Mr [name redacted] falls history could not be shared by his Social Worker with other relevant Multi Agencies such as Milford House or the Health Team at the time his Pre Admission Assessment was undertaken as the process/system did not allow it.”
judiciary.uk/prevention-of-future-death-reports/charles-grainger
What was promised
No published response from Derbyshire County Council was found for the earlier reports.
What recurred
- 25 Feb 2026 · Emma Turner · Sabyta Kaushal · Identical hazard · confidence 0.93 (high)
The clearest link, quoted from both reports:
Earlier · Charles Grainger · 12 May 2018
“Relevant information regarding Mr [name redacted] falls history could not be shared by his Social Worker with other relevant Multi Agencies such as Milford House or the Health Team at the time his Pre Admission Assessment was undertaken as the process/system did not allow it.”
Later · Emma Turner · 25 Feb 2026
“The evidence at the inquest revealed a lack of connectivity between information systems used by different agencies; that impacted on their ability to review how other professionals would intervene in [the deceased]'s care.”
What happened next
No web check of the stated actions has been published for this chain.