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recurance

Sarah Holmes

11 Oct 2023 · Coroner Janine Richards · County Durham and Darlington

This report repeats 1 earlier warning. See the linked reports.

The coroner's concerns

  1. 1. delayed serious incident investigation

    “The serious incident investigation remained unallocated and with no timeframe for completion for over 7 months”

Linked reports

Repeats an earlier warningMary Waldron10 Jan 2014 · 9 years 9 months earlier
Closely relatedConfidence 0.90 · high

Earlier report

“failure of the nursing home managers to undertake an effective investigation into this incident and to take action to prevent repetition”
Original on judiciary.uk ↗

This report

“The serious incident investigation remained unallocated and with no timeframe for completion for over 7 months”
Full chain: Delayed and ineffective incident investigations by managers

Responses

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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