Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Dorothy Imisson · 5 Apr 2016 · James Adeley, Preston and West Lancashire
“(1) No appropriate care plan was developed by the District Nursing Service.”
judiciary.uk/prevention-of-future-death-reports/dorothy-imisson
What was promised
Stated action 1 · response to Ronald Farrington (22 Dec 2017) · stated 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.”
judiciary.uk/wp-content/uploads/2017/12/2017-0494-Response.pdf
Stated action 2 · response to Ronald Farrington (22 Dec 2017) · stated timescale: none stated
“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”
Stated action 3 · response to Susan Bracegirdle (2 Feb 2024) · stated timescale: none stated
“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.”
judiciary.uk/…/2024-0052-Response-from-Greater-Manchester-Integ…
2 further stated actions are listed on the full chain page.
What recurred
- 22 Dec 2017 · Ronald Farrington · Caroline Topping
- 8 Dec 2021 · Rebecca Begg · Dr Elizabeth Didcock
- 2 Feb 2024 · Susan Bracegirdle · Alison Mutch
- 15 Jan 2026 · Ronald Nelson · Sarah Wood · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Rebecca Begg · 8 Dec 2021
“Failure to monitor compliance with care plans, and a lack of robust incident”
Later · Ronald Nelson · 15 Jan 2026
“There are concerns over the level of compliance of care plans.”
What happened next
No evidence found either way · stated action 1
“Multidisciplinary perspectives on opportunities, challenges and implications of generative conversational AI for research, practice and policy”
Opinion Paper: “So what if ChatGPT wrote it?” Multidisciplinary perspectives on opportunities, challenges and implications of generative conversational AI for research, practice and policy · sciencedirect.com/science/article/pii/S0268401223000233
“Streamlining supervision, safeguarding resilience: the ECB's agenda for more effective, efficient and risk-based European banking supervision”
Streamlining supervision, safeguarding resilience: the ECB’s agenda for more effective, efficient and risk-based European banking supervision · bankingsupervision.europa.eu/…/ssm.streamlining_supervision2025…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“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.”
New platform for AsureQuality Auditing Services · asurequality.com/…/new-platform-for-asurequality-auditing-servi…
No evidence found does not mean the action did not happen.