Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate window restrictor strength in care settings
The earlier warning
Stephen Verrall · 1 Oct 2021 · Jonathan Landau, South London
“I was informed that CQC did not routinely check window restrictors on inspections.”
judiciary.uk/…/stephen-verrall-prevention-of-future-deaths-repo…
What was promised
Stated action 1 · response to Stephen Verrall (1 Oct 2021) · stated timescale: next inspection
“We will check at our next inspection that these changes have been embedded at St John's Nursing Home and that these were effectively minimising risks where these had been identified.”
judiciary.uk/…/2021-0336-Response-from-Care-Quality-Commission_…
What recurred
- 21 Jun 2024 · Terrence Taylor · Keith Morton · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Stephen Verrall · 1 Oct 2021
“I was informed that CQC did not routinely check window restrictors on inspections.”
Later · Terrence Taylor · 21 Jun 2024
“it is suggested that window restrictors (and their fixings) are capable of withstanding push forces of at least 850N”
What happened next
No web check of the stated actions has been published for this chain.