Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate documentation of care and risk
The earlier warning
Frederick Boyd · 2 May 2024 · Alison Mutch, Manchester South
“there was no clear system or expectation regarding the quality of checks on a resident who exhibited signs of being unwell.”
judiciary.uk/…/frederick-boyd-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Frederick Boyd (2 May 2024) · stated timescale: 26 July 2024
“we will require the registered provider to provide an action plan with clear timescales for completion of each action identified and will review progress against this action plan in line with our processes.”
judiciary.uk/…/2024-0240-Response-from-Lakes-Care-Centre-and-CQ…
What recurred
- 14 Nov 2025 · Ronald Perry · Alison Mutch · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Frederick Boyd · 2 May 2024
“there was no clear system or expectation regarding the quality of checks on a resident who exhibited signs of being unwell.”
Later · Ronald Perry · 14 Nov 2025
“During the course of the inquest it was difficult to be clear at times as to what care had been delivered or what steps had been taken because the documentation relating to care and risk was poor.”
What happened next
No web check of the stated actions has been published for this chain.