Inadequate investigation documentation and delayed safety disclosure
Care UK received 2 coroners' reports about this hazard between 6 Jun 2023 and 20 Dec 2024.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from Care UK was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“Evidence was given that an investigation was carried out - despite no written document/ record of this being made - and the manager being unable even to name the care staff involved in the incident.”
Original on judiciary.uk ↗ No published response from Care UK was found for this report.
- 1 year 6 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“The Deputy Manager who had drafted this handover document, was also responsible for the care home's own internal investigation into Mrs. [name redacted] fall. That internal investigation failed to highlight the deficiencies in the handover document, and the handover document itself was not disclosed to the Coroner's Office until the final inquest hearing was underway.”
Original on judiciary.uk ↗ Repeated from the earlier report:Managerdocumentcareinvestigation
Care UK responded, stating 5 specific actions.Response (PDF) ↗
“All care plans at Chandler Court care home are being audited to ensure that there are no ambiguous instructions in relation to residents' care needs. This review includes moving and handling, and personal care needs. Currently 20 care plans have been audited and we expect to complete the remainder by close of business tomorrow; 14 February 2025”
Stated timescale: 14 February 2025
“Since the Inquest hearing, the entire care team at Chandler Court has received supervisory training highlighting the importance of reading and understanding care plans and reiterating the relevant components of the Care UK e-learning programme”
3 more stated actions in the Promises tab.
- All reports to Care UK
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2023 → 2024Edith Pye1 year 6 months after Jennifer Rackley · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports criticize the care home's internal investigations for lacking proper documentation and failing to identify safety shortcomings.
Jennifer Rackley · 6 Jun 2023
“Evidence was given that an investigation was carried out - despite no written document/ record of this being made - and the manager being unable even to name the care staff involved in the incident.”
Original on judiciary.uk ↗ Edith Pye · 20 Dec 2024
“The Deputy Manager who had drafted this handover document, was also responsible for the care home's own internal investigation into Mrs. [name redacted] fall. That internal investigation failed to highlight the deficiencies in the handover document, and the handover document itself was not disclosed to the Coroner's Office until the final inquest hearing was underway.”
Original on judiciary.uk ↗
No published response from Care UK was found for this report.
Stated action · timescale: 14 February 2025
“All care plans at Chandler Court care home are being audited to ensure that there are no ambiguous instructions in relation to residents' care needs. This review includes moving and handling, and personal care needs. Currently 20 care plans have been audited and we expect to complete the remainder by close of business tomorrow; 14 February 2025”
Stated action
“Since the Inquest hearing, the entire care team at Chandler Court has received supervisory training highlighting the importance of reading and understanding care plans and reiterating the relevant components of the Care UK e-learning programme”
Stated action
“All Care UK employees receive Safeguarding and Protection of Vulnerable Adults eLearning training during their induction programme. This training covers the Care UK Whistleblowing policy and ensures that colleagues understand their right and duty to raise concerns”
Stated action
“Care UK has reviewed our handover templates to ensure that they highlight the key aspects of each resident's care needs”
Stated action · timescale: September 2024
“In September 2024 Care UK introduced a revised Safety Incident Response Framework (SIRF) policy based on”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Care UK at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2023 → 2024 | 0.72 | 0.09 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Care UK
- Missing follow up of non attendance at reception healthcare screening3 reports · 2016–2019
- Lack of relevant information sharing during ACCT reviews2 reports · 2014–2017
- Inadequate ACCT document review and agency input documentation3 reports · 2014–2017
- Lack of depression management documentation and screening2 reports · 2016–2016
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.