Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of nighttime visual monitoring of vulnerable individual
The earlier warning
James Clarke · 10 Sept 2014 · Robin Balmain, Black Country
“Call is to check [the deceased] throughout the night and carry out tracheotomy care/suction if necessary”
judiciary.uk/prevention-of-future-death-reports/james-clarke
What was promised
Stated action 1 · response to James Clarke (10 Sept 2014) · stated timescale: May 2011
“We have had a number of changes in structures and personnel since the time of Mr [name redacted] death, so I am somewhat reliant on information from our computer record systems to provide the following information.”
judiciary.uk/…/2014-0398-Response-by-Care-Quality-Commission.pdf
What recurred
- 15 May 2022 · Connor Wellsted · Karen Henderson · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · James Clarke · 10 Sept 2014
“Call is to check [the deceased] throughout the night and carry out tracheotomy care/suction if necessary”
Later · Connor Wellsted · 15 May 2022
“[the deceased] had no regular or direct visual supervision during the night (other than to open the door of his room to check if there was a smell)”
What happened next
No web check of the stated actions has been published for this chain.