Inadequate nighttime staffing for dementia residents
Care Quality Commission received 2 coroners' reports about this hazard between 11 Nov 2013 and 27 Feb 2020.
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 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Staff both during the day and night need to be able to give attention to residents.”
Original on judiciary.uk ↗ Care Quality Commission responded.Response (PDF) ↗Response (PDF) ↗
- 6 years 4 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“Evidence emerged during the inquest.that Normanton Village View Nursing Home had no formal policies covering how residents were to be observed, how foods were to be stored, locks on the kitchen and cupboards, dementia”
Original on judiciary.uk ↗ Repeated from the earlier report:duringresidents
The most recent report. A response may not be due or published yet.
- 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.
2013 → 2020Kenneth Clarke6 years 4 months after John Gwynfryn Morris · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight insufficient supervision of residents with dementia, raising risks of unsafe wandering or unmet needs. The earlier report stresses the need for staff attention, while the later report points out missing formal policies for observation.
John Gwynfryn Morris · 11 Nov 2013
“Staff both during the day and night need to be able to give attention to residents.”
Original on judiciary.uk ↗ Kenneth Clarke · 27 Feb 2020
“Evidence emerged during the inquest.that Normanton Village View Nursing Home had no formal policies covering how residents were to be observed, how foods were to be stored, locks on the kitchen and cupboards, dementia”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No published response from Care Quality Commission was found for this report. It is the most recent report, so a response may not be due or published yet.
- 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 |
|---|---|---|---|---|
| 2013 → 2020 | 0.62 | 0.19 | Closely related · 0.80 | 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.