Victor Knowles

“The evidence highlighted that there was no mechanism for lessons to be learned from deaths which occur during or following admission to the Nursing Home.”

“The evidence highlighted that there had been little reflection upon the events leading up to [the deceased]'s death, with no facility for the identification of any missed opportunities to provide or obtain care for [the deceased] prior to his final admission to hospital.”

“The evidence highlighted that the only internal investigation that took place in respect of the care provided to [the deceased] was in the context of safeguarding and as a consequence of a request from the Local Authority, under section 42 of the Care Act 2014, following the submission of safeguarding referrals by the Hospital after [the deceased]'s death.”

“Although an internal review of the care arrangements in place for [the deceased] took place alongside the internal investigation, the purpose of this was to identify any further opportunities to strengthen existing procedures, rather than to identify any areas of learning and improvements that could have been made in respect of [the deceased]'s care.”