Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
David Sheppard · 8 May 2017 · Louise Hunt, Birmingham and Solihull
“Staff failed to keep an acute and contemporaneous note of the events that occurred with timings.”
judiciary.uk/prevention-of-future-death-reports/david-sheppard
What was promised
Stated action 1 · response to David Sheppard (8 May 2017) · stated timescale: none stated
“the provider has taken a number of measures to address concerns including, but not limited to, the provision of training with first aid, CPR and choking prioritised in the induction process, as well as documentation training sessions and the introduction of an incident reporting questionnaire”
Stated action 2 · response to James Harris (21 Jul 2017) · stated timescale: none stated
“The Registered Provider is responsible for ensuring care staff are competent, skilled and experienced and that they are appropriately trained as is necessary to enable them to carry out their duties, (Regulation 12 the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).The Registered Provider has the responsibility to ensure care staff follow service users care plans, and to make staff aware of the importance of knowing how to effectively and safely support service users and”
judiciary.uk/…/2017-0334-Response-by-Care-Quality-Commission.pdf
Stated action 3 · response to Ronald Farrington (22 Dec 2017) · stated timescale: December 2017
“We have improved our systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion. In December 2016 15% of our adult safeguarding enquiries had been in progress for over 12 months. By December 2017 we had reduced this to 4%, despite the number of adult safeguarding enquiries we are undertaking having more than doubled over that period.”
judiciary.uk/wp-content/uploads/2017/12/2017-0494-Response.pdf
4 further stated actions are listed on the full chain page.
What recurred
- 21 Jul 2017 · James Harris · Emma Brown
- 22 Dec 2017 · Ronald Farrington · Caroline Topping
- 2 Dec 2019 · Sidney Baker · Rachel Syed · Closely related · confidence 0.85 (high)
- 1 Dec 2020 · Anthony Slack · Alison Mutch
- 22 Jul 2021 · John Dickinson · Sarah Watson · Closely related · confidence 0.90 (high)
- 15 Nov 2022 · Frederick King · Jenny Goldring · Identical hazard · confidence 0.90 (high)
- 10 Sept 2024 · James Astley · Alison Mutch · Identical hazard · confidence 0.90 (high)
- 15 Jan 2026 · Ronald Nelson · Sarah Wood · Identical hazard · confidence 0.90 (high)
- 26 Jun 2026 · Susan Dale · Sally Robinson · Identical hazard · confidence 0.95 (high)
The clearest link, quoted from both reports:
Earlier · Sidney Baker · 2 Dec 2019
“There were concerns that entries contained in Mr [name redacted] care plan were incorrect, including vital information contained on his weight monitoring sheet. Furthermore, the general quality of record keeping was poor.”
Later · Susan Dale · 26 Jun 2026
“(1) The record keeping in the home appeasers to be inaccurate and inconsistent”
What happened next
No evidence found either way · stated action 1
“Utilize the checklist below to complete your initial incident report.”
[PDF] Choking Incident Report Checklist - NJ.gov · nj.gov/…/choking-checklist.pdf
“FirstAidTraining can teach you to: ✓Identify and treat a choking incident”
First Aid training can teach you to: 1️⃣Identify and treat a ... · facebook.com/…/1390380509940641
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
The Care Quality Commission provides guidance on staffing and training requirements but does not specify a completion timeframe for staff training.
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“Multidisciplinary perspectives on opportunities, challenges and implications of generative conversational AI for research, practice and policy”
Opinion Paper: “So what if ChatGPT wrote it?” Multidisciplinary perspectives on opportunities, challenges and implications of generative conversational AI for research, practice and policy · sciencedirect.com/science/article/pii/S0268401223000233
“Streamlining supervision, safeguarding resilience: the ECB's agenda for more effective, efficient and risk-based European banking supervision”
Streamlining supervision, safeguarding resilience: the ECB’s agenda for more effective, efficient and risk-based European banking supervision · bankingsupervision.europa.eu/…/ssm.streamlining_supervision2025…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “we have put in place a new auditing system with close support from the local quality development team from East Surrey, this has been developed over the past year and has been met with positive feedback from the local team. The”
“To advance the digitalisation of our auditing and certification services and to support the future of food assurance, AsureQuality is partnering with Intact - a market leader in quality assurance software solutions for food industry certification, to implement a new Audit Management System.”
New platform for AsureQuality Auditing Services · asurequality.com/…/new-platform-for-asurequality-auditing-servi…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “Council's considerations and investigation: Following Mr [name redacted] death, several monitoring and support visits took place at Barely Brook. We considered a sample of referrals that had been made in respect of current residents. Wigan Council can confirm that the recording of referrals of any kind (including dietician and falls team, and referrals to the Later Life and Memory Team) has improved. Barley Brook has demonstrated they are now keeping contemporaneous records and documentation.”
“Baseline referral documentation averaged fewer than two referrals per w”
Improving Referral and Continuity of Care Through Structured Outpatient Disposition Planning Enabled by Electronic Referrals: A Quality Improvement Study · pmc.ncbi.nlm.nih.gov/articles/PMC12869834
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “We will carry out a further comprehensive inspection within 12 months, to ensure action has been taken and the provider is no longer in breach.”
“The Care Quality Commission is overhauling how it works. After a rough couple of years - inspection backlogs, mounting criticism, internal problems - the regulator has new leadership and a plan to fix things by the end of 2026. If you run a care service, these changes will affect how you're assessed.”
CQC's 2026 Overhaul: New Leadership, Cleared Backlogs, New Rules — Team Care Compliance · teamcarecompliance.org.uk/…/cqc-2026-reset-what-providers-need-…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The provider has indicated they have also reviewed the quality of their own documentation and care records. In relation to food records, in addition to improved documentation, staff have also received additional training.”
“Documentation represents far more than administrative paperwork. Clear, accurate record-keeping forms the backbone of quality care delivery, protecting both residents and the professionals who serve them. When direct care staff understand documentation's vital role and receive proper training in record-keeping practices, they gain confidence in their professional capabilities while creating”
Documentation That Protects: How Clear Record-Keeping ... · yourtrainingprovider.com/…/documentation-that-protects-how-clea…
No evidence found does not mean the action did not happen.