Ian Simpson

“Mr [name redacted] was found unresponsive by care home staff at about 09:30 on 16 December 2024, and an emergency ambulance was not called until 10:19. On the evidence in this particular case, that delay did not more than minimally contribute to death; however, it would or should have been obvious to staff that the resident was very unwell and required an ambulance as soon as possible.”

“The notes from the care home were considered in great detail during the inquest, particularly the care notes from the morning of 16 December 2024. These raised significant concern about their adequacy and accuracy. While the deficiencies in record-keeping did not cause or contribute to death in the specific circumstances of this case, I am mindful of the importance of clear and accurate record- keeping to the delivery of safe and effective care more widely.”