James Clarke
10 Sept 2014 · Coroner Robin Balmain · Black Country
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of supervision of James during night hours
“Call is to check [the deceased] throughout the night and carry out tracheotomy care/suction if necessary”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“Call is to check [the deceased] throughout the night and carry out tracheotomy care/suction if necessary”
Later report
“[the deceased] had no regular or direct visual supervision during the night (other than to open the door of his room to check if there was a smell)”
Responses
2014-0398-Response-by-Care-Quality-Commission.pdf ↗· Care Quality Commission
Stated action · May 2011
“We have had a number of changes in structures and personnel since the time of Mr [name redacted] death, so I am somewhat reliant on information from our computer record systems to provide the following information.”