Non‑compliance with care plans and insufficient incident review
Care Quality Commission received 5 coroners' reports about this hazard between 5 Apr 2016 and 15 Jan 2026.
They came from 5 different coroners in 5 coroner areas. A similar concern was raised again 4 times after the first warning.
A published response was found for 3 of the 4 earlier reports, stating 5 specific actions.
The story, report by report
Spacing grows with the time between reports.
“(1) No appropriate care plan was developed by the District Nursing Service.”
Original on judiciary.uk ↗ No published response from Care Quality Commission was found for this report.
- 1 year 9 months later
“Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr [name redacted] sores”
Original on judiciary.uk ↗ Care Quality Commission responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“We have improved our systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion. In December 2016 15% of our adult safeguarding enquiries had been in progress for over 12 months. By December 2017 we had reduced this to 4%, despite the number of adult safeguarding enquiries we are undertaking having more than doubled over that period.”
Stated timescale: December 2017
Web search (Tavily): No evidence found either way
Opinion Paper: “So what if ChatGPT wrote it?” Multidisciplinary perspectives on opportunities, challenges and implications of generative conversational AI for research, practice and policy ↗“we have put in place a new auditing system with close support from the local quality development team from East Surrey, this has been developed over the past year and has been met with positive feedback from the local team. The”
Web search (Tavily): No evidence found either way
New platform for AsureQuality Auditing Services ↗ - 4 years later
“Failure to monitor compliance with care plans, and a lack of robust incident”
Original on judiciary.uk ↗ Care Quality Commission responded.Response (PDF) ↗
- 2 years 2 months later
“The inquest heard evidence that because Mrs [name redacted] was in a care home setting the District Nurses were responsible for management of her pressure ulcers.”
Original on judiciary.uk ↗ Care Quality Commission responded, stating 3 specific actions.Response (PDF) ↗Response (PDF) ↗
“We have reviewed all our records and cannot find that we received a statutory notification for serious injury to Mrs [name redacted] in relation to the grade 3 pressure injury identified at the point it was identified in October 2022.”
“The care home was asked to ensure pressure relieving processes were followed. However, the District Nurses did not share care plans with the care team on the basis that they were digital documents and were care plans for the use of District Nurses. Consequently, the care home management were not fully sighted, and joint care was more difficult to deliver increasing the risk of the pressure ulcers deteriorating.”
1 more stated action in the Promises tab.
- 1 year 11 months laterClosely relatedConfidence 0.90 · higha different coroner
“There are concerns over the level of compliance of care plans.”
Original on judiciary.uk ↗ Repeated from the earlier report:compliancecareplans
Care Quality Commission responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Care Quality Commission
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.
2021 → 2026Ronald Nelson4 years 1 month after Rebecca Begg · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with ensuring that care plans are followed correctly.
Rebecca Begg · 8 Dec 2021
“Failure to monitor compliance with care plans, and a lack of robust incident”
Original on judiciary.uk ↗ Ronald Nelson · 15 Jan 2026
“There are concerns over the level of compliance of care plans.”
Original on judiciary.uk ↗ 2016 → 2026Ronald Nelson9 years 9 months after Dorothy Imisson · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with the creation and adherence to care plans by district nursing services. The earlier report notes missing care plans, while the later report flags ongoing compliance issues.
Dorothy Imisson · 5 Apr 2016
“(1) No appropriate care plan was developed by the District Nursing Service.”
Original on judiciary.uk ↗ Ronald Nelson · 15 Jan 2026
“ii) There are concerns over the level of compliance of care plans.”
Original on judiciary.uk ↗ 2017 → 2026Ronald Nelson8 years 1 month after Ronald Farrington · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight failures to properly implement and document care plan recommendations.
Ronald Farrington · 22 Dec 2017
“Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr [name redacted] sores”
Original on judiciary.uk ↗ Ronald Nelson · 15 Jan 2026
“There are concerns over the level of compliance of care plans.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We have improved our systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion. In December 2016 15% of our adult safeguarding enquiries had been in progress for over 12 months. By December 2017 we had reduced this to 4%, despite the number of adult safeguarding enquiries we are undertaking having more than doubled over that period.”
2024 → 2026Ronald Nelson1 year 11 months after Susan Bracegirdle · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight problems with how care plans are documented and shared between district nurses and care home staff. The earlier report focuses on non‑sharing of digital care plans, while the later report notes ongoing concerns about care plan compliance and record keeping.
Susan Bracegirdle · 2 Feb 2024
“The inquest heard evidence that because Mrs [name redacted] was in a care home setting the District Nurses were responsible for management of her pressure ulcers.”
Original on judiciary.uk ↗ Ronald Nelson · 15 Jan 2026
“ii) There are concerns over the level of compliance of care plans.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“Whenever a District Nurse attends a resident at Stable Steps any advice in relation to the management of pressure ulcers is shared with the team via a Communication Book.”
No published response from Care Quality Commission was found for this report.
Stated action · timescale: December 2017
“We have improved our systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion. In December 2016 15% of our adult safeguarding enquiries had been in progress for over 12 months. By December 2017 we had reduced this to 4%, despite the number of adult safeguarding enquiries we are undertaking having more than doubled over that period.”
What happened next: No evidence found either way
The organisation's statement about reducing long-term adult safeguarding enquiries to 4% by December 2017 is not addressed in any of the provided sources.
“Multidisciplinary perspectives on opportunities, challenges and implications of generative conversational AI for research, practice and policy”
“Streamlining supervision, safeguarding resilience: the ECB's agenda for more effective, efficient and risk-based European banking supervision”
No evidence found does not mean the action did not happen.
Stated action
“we have put in place a new auditing system with close support from the local quality development team from East Surrey, this has been developed over the past year and has been met with positive feedback from the local team. The”
What happened next: No evidence found either way
The organisation announced plans to implement a new auditing system with support from the local quality development team, but no source confirms the system was fully operational or delivered as promised.
“To advance the digitalisation of our auditing and certification services and to support the future of food assurance, AsureQuality is partnering with Intact - a market leader in quality assurance software solutions for food industry certification, to implement a new Audit Management System.”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
Stated action
“We have reviewed all our records and cannot find that we received a statutory notification for serious injury to Mrs [name redacted] in relation to the grade 3 pressure injury identified at the point it was identified in October 2022.”
Stated action
“The care home was asked to ensure pressure relieving processes were followed. However, the District Nurses did not share care plans with the care team on the basis that they were digital documents and were care plans for the use of District Nurses. Consequently, the care home management were not fully sighted, and joint care was more difficult to deliver increasing the risk of the pressure ulcers deteriorating.”
Stated action
“Whenever a District Nurse attends a resident at Stable Steps any advice in relation to the management of pressure ulcers is shared with the team via a Communication Book.”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- 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 Quality Commission 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 |
|---|---|---|---|---|
| 2021 → 2026 | 0.71 | 0.38 | Closely related · 0.90 | different |
| 2016 → 2026 | 0.70 | 0.12 | Closely related · 0.90 | different |
| 2017 → 2026 | 0.75 | 0.18 | Closely related · 0.85 | different |
| 2024 → 2026 | 0.78 | 0.17 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Care Quality Commission
- Inaccurate and inconsistent care plan entries and record keeping10 reports · 2017–2026
- Ambulance handover delays at hospitals reduce availability3 reports · 2015–2026
- Inadequate repositioning and monitoring of at-risk patients2 reports · 2013–2025
- Missing falls prevention equipment in resident care2 reports · 2018–2025
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.