Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate investigation documentation and delayed safety disclosure
The earlier warning
Jennifer Rackley · 6 Jun 2023 · Heidi Connor, Berkshire
“Evidence was given that an investigation was carried out - despite no written document/ record of this being made - and the manager being unable even to name the care staff involved in the incident.”
judiciary.uk/…/jennifer-rackley-prevention-of-future-deaths-rep…
What was promised
No published response from Care UK was found for the earlier reports.
What recurred
- 20 Dec 2024 · Edith Pye · David Reid · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Jennifer Rackley · 6 Jun 2023
“Evidence was given that an investigation was carried out - despite no written document/ record of this being made - and the manager being unable even to name the care staff involved in the incident.”
Later · Edith Pye · 20 Dec 2024
“The Deputy Manager who had drafted this handover document, was also responsible for the care home's own internal investigation into Mrs. [name redacted] fall. That internal investigation failed to highlight the deficiencies in the handover document, and the handover document itself was not disclosed to the Coroner's Office until the final inquest hearing was underway.”
What happened next
No web check of the stated actions has been published for this chain.