Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate repositioning and monitoring of at-risk patients
The earlier warning
Mohammed Chaudhury · 20 Aug 2013 · Andrew Harris, London (Inner South)
“Infected pressure sores may have been a cause of death and they were unusual in extent and severity.”
What was promised
No published response from Care Quality Commission was found for the earlier reports.
What recurred
- 19 Dec 2025 · Ramona Harbott · Susan Ridge · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Mohammed Chaudhury · 20 Aug 2013
“Infected pressure sores may have been a cause of death and they were unusual in extent and severity.”
Later · Ramona Harbott · 19 Dec 2025
“The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff.”
What happened next
No web check of the stated actions has been published for this chain.