Lack of personal care and health deterioration in domiciliary care
Department of Health and Social Care received 2 coroners' reports about this hazard between 31 Aug 2023 and 22 Jul 2024.
They came from 1 coroner. 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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“Since 2020 Ms [name redacted] had been provided with domiciliary care commissioned by the local authority. At the time of her death twice daily visits were undertaken. Ms [name redacted] was utilising state funded domiciliary care visits to deliver fast food to her home, no personal care was being provided.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“include: increasing nursing capacity; holding weekly multidisciplinary Complex Case discussion meetings; updating the risk escalation process; devising standardised operating procedure relating to how district nurses conduct their daily handovers; providing relevant training for health and social care staff; making the completion of mental capacity assessments in complex cases mandatory; undertaking risk assessments to identify anxiety and depression scores; increasing frequency of high risk cases”
Stated timescale: 09/11/23
- 11 months laterClosely relatedConfidence 0.85 · high
“Poor standards of communication between the domiciliary care company, the local authority and NHS trust resulted in a failure to identify the deterioration in Mr [name redacted] living conditions and health.”
Original on judiciary.uk ↗ Repeated from the earlier report:domiciliarycarelocalauthority
Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Department of Health and Social Care
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 → 2024Omar Ahmed11 months after Donna Levy · same coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight that domiciliary care funded by the state was being used for non‑care purposes (food delivery or pub/café trips) instead of providing personal care. They also point to inadequate communication and oversight between care providers, commissioners and NHS services as a contributing factor.
Donna Levy · 31 Aug 2023
“Since 2020 Ms [name redacted] had been provided with domiciliary care commissioned by the local authority. At the time of her death twice daily visits were undertaken. Ms [name redacted] was utilising state funded domiciliary care visits to deliver fast food to her home, no personal care was being provided.”
Original on judiciary.uk ↗ Omar Ahmed · 22 Jul 2024
“Poor standards of communication between the domiciliary care company, the local authority and NHS trust resulted in a failure to identify the deterioration in Mr [name redacted] living conditions and health.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“Review, revise and disseminate the risk escalation process with health and social care staff.”
Stated action · timescale: 09/11/23
“include: increasing nursing capacity; holding weekly multidisciplinary Complex Case discussion meetings; updating the risk escalation process; devising standardised operating procedure relating to how district nurses conduct their daily handovers; providing relevant training for health and social care staff; making the completion of mental capacity assessments in complex cases mandatory; undertaking risk assessments to identify anxiety and depression scores; increasing frequency of high risk cases”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
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 Department of Health and Social Care 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 | 0.73 | 0.31 | Closely related · 0.85 | same |
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.