Inaccurate documentation of deceased patients
Nursing and Midwifery Council received 2 coroners' reports about this hazard between 29 Jul 2019 and 2 Aug 2024.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“During the course of the inquest, the evidence revealed concerns with the implications of the evidence of three witnesses employed by NHS Professionals at times when the deceased was already dead.”
Original on judiciary.uk ↗ Nursing and Midwifery Council responded, stating 1 specific action.Response (PDF) ↗
“| have passed your report regarding the two registered nurses to our Fitness to Practise team for further investigation; we have now also received a formal referral from NHS Professionals in respect of these two nurses. The case of the two nurses is now with our screening team and they will use the information we have received from your office and NHS Professionals to consider the matter further.”
- 5 years laterClosely relatedConfidence 0.85 · higha different coroner
“(1) To Westmorland Court. The General Practitioner who came to give evidence said that care had improved since Reg's death but he still had concerns about care given and had to visit regularly every week to check residents -the only one of six homes he covers that requires this level of support. He said it was a struggle to provide good quality care and felt this report would be helpful -as I stated at inquest it is not intended in any way to be punitive but to put focus on areas that may be im”
Original on judiciary.uk ↗ Repeated from the earlier report:evidenceconcernsinquest
Nursing and Midwifery Council responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“we have passed this information on to our Employer Link Service (ELS) and to the New Referrals team to make enquiries in relation to these concerns.”
“We are grateful for the details provided in your report and confirmation of the outcome following inquest. With regards your query in relation to CQC making further enquiries, we have taken action as outlined below. CQC were informed of the outcome of the local authority safeguarding investigation into the use of CPR on 1 December 2021 including actions to be taken to prevent further incidents. Actions included internal investigation by the provider, audit of the incident, a refresher of basic”
Stated timescale: 1 December 2021
- All reports to Nursing and Midwifery Council
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.
2019 → 2024James Capstick5 years after Alex Blake · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight concerns that nursing staff produced inaccurate records or observations about patients who were already deceased or unavailable, undermining the reliability of clinical documentation.
Alex Blake · 29 Jul 2019
“During the course of the inquest, the evidence revealed concerns with the implications of the evidence of three witnesses employed by NHS Professionals at times when the deceased was already dead.”
Original on judiciary.uk ↗ James Capstick · 2 Aug 2024
“(1) To Westmorland Court. The General Practitioner who came to give evidence said that care had improved since Reg's death but he still had concerns about care given and had to visit regularly every week to check residents -the only one of six homes he covers that requires this level of support. He said it was a struggle to provide good quality care and felt this report would be helpful -as I stated at inquest it is not intended in any way to be punitive but to put focus on areas that may be im”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“| have passed your report regarding the two registered nurses to our Fitness to Practise team for further investigation; we have now also received a formal referral from NHS Professionals in respect of these two nurses. The case of the two nurses is now with our screening team and they will use the information we have received from your office and NHS Professionals to consider the matter further.”
Stated action
“| have passed your report regarding the two registered nurses to our Fitness to Practise team for further investigation; we have now also received a formal referral from NHS Professionals in respect of these two nurses. The case of the two nurses is now with our screening team and they will use the information we have received from your office and NHS Professionals to consider the matter further.”
Stated action
“we have passed this information on to our Employer Link Service (ELS) and to the New Referrals team to make enquiries in relation to these concerns.”
Stated action · timescale: 1 December 2021
“We are grateful for the details provided in your report and confirmation of the outcome following inquest. With regards your query in relation to CQC making further enquiries, we have taken action as outlined below. CQC were informed of the outcome of the local authority safeguarding investigation into the use of CPR on 1 December 2021 including actions to be taken to prevent further incidents. Actions included internal investigation by the provider, audit of the incident, a refresher of basic”
- 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 Nursing and Midwifery Council 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 |
|---|---|---|---|---|
| 2019 → 2024 | 0.67 | 0.06 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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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.