Lack of nighttime visual monitoring of vulnerable individual
Care Quality Commission received 2 coroners' reports about this hazard between 10 Sept 2014 and 15 May 2022.
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 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Call is to check [the deceased] throughout the night and carry out tracheotomy care/suction if necessary”
Original on judiciary.uk ↗ Care Quality Commission responded, stating 1 specific action.Response (PDF) ↗
“We have had a number of changes in structures and personnel since the time of Mr [name redacted] death, so I am somewhat reliant on information from our computer record systems to provide the following information.”
Stated timescale: May 2011
- 7 years 8 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“[the deceased] had no regular or direct visual supervision during the night (other than to open the door of his room to check if there was a smell)”
Original on judiciary.uk ↗ Repeated from the earlier report:nightcheck
Care Quality Commission responded, stating 1 specific action.Response (PDF) ↗
“The cot used for [the deceased] during this admission was not a standard piece of equipment used by staff at TCT and they were unfamiliar with its use. This type of cot is no longer in use at TCT and all specialist cots have been replaced with equipment compliant with current bed standards. (BS EN 50637:2017 - Medical electrical equipment - Particular requirements for the basic safety and essential performance of medical beds for children).”
Stated timescale: 20220627
- 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.
2014 → 2022Connor Wellsted7 years 8 months after James Clarke · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight insufficient night-time supervision or checks of a vulnerable individual, leading to preventable harm.
James Clarke · 10 Sept 2014
“Call is to check [the deceased] throughout the night and carry out tracheotomy care/suction if necessary”
Original on judiciary.uk ↗ Connor Wellsted · 15 May 2022
“[the deceased] had no regular or direct visual supervision during the night (other than to open the door of his room to check if there was a smell)”
Original on judiciary.uk ↗
Stated action · timescale: May 2011
“We have had a number of changes in structures and personnel since the time of Mr [name redacted] death, so I am somewhat reliant on information from our computer record systems to provide the following information.”
Stated action · timescale: 20220627
“The cot used for [the deceased] during this admission was not a standard piece of equipment used by staff at TCT and they were unfamiliar with its use. This type of cot is no longer in use at TCT and all specialist cots have been replaced with equipment compliant with current bed standards. (BS EN 50637:2017 - Medical electrical equipment - Particular requirements for the basic safety and essential performance of medical beds for children).”
- 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 |
|---|---|---|---|---|
| 2014 → 2022 | 0.78 | 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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- Non‑compliance with care plans and insufficient incident review5 reports · 2016–2026
- Inadequate repositioning and monitoring of at-risk patients2 reports · 2013–2025
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.