Skip to content
recurance

Donald Elliott

12 Feb 2020 · Coroner Paul Cooper · Lincolnshire

The coroner's concerns

  1. 1. staffing levels at time of fall

    “Please confirm the level of staffing present on 24/01/2019 and 31/01/2019 at the time the deceased was recorded as falling”
  2. 2. compliance with Regulation 18

    “Is the Care Home able to evidence and demonstrate on both dates they complied with Regulation 18 Health and Social Care Act 2008 as to: a) Deploying enough suitably qualified competent and experienced staff and, b) That those staff received the support, training, professional development, supervision and appraisals that are necessary for them to carry out their role and responsibilities”
  3. 3. witness non-attendance at inquest

    “This report is raised due to the contradictory evidence filed in the Inquest for and on behalf of Glenholme Holdingham Grange Care Home and to ascertain why the coronial service was only notified the day before the Inquest why 2 witnesses formerly engaged by the Care Home failed to attend the inquest under summons”

Responses

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error