Recurance · prevention of future deaths reports
Pre-inquest brief
Delayed and ineffective incident investigations by managers
The earlier warning
Mary Waldron · 10 Jan 2014 · R Brittain, Coventry
“failure of the nursing home managers to undertake an effective investigation into this incident and to take action to prevent repetition”
judiciary.uk/prevention-of-future-death-reports/mary-waldron
What was promised
No published response from Care Quality Commission was found for the earlier reports.
What recurred
- 11 Oct 2023 · Sarah Holmes · Janine Richards · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Mary Waldron · 10 Jan 2014
“failure of the nursing home managers to undertake an effective investigation into this incident and to take action to prevent repetition”
Later · Sarah Holmes · 11 Oct 2023
“The serious incident investigation remained unallocated and with no timeframe for completion for over 7 months”
What happened next
No web check of the stated actions has been published for this chain.