Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of personal care and health deterioration in domiciliary care
The earlier warning
Donna Levy · 31 Aug 2023 · Graeme Irvine, East London
“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.”
judiciary.uk/…/donna-levy-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Donna Levy (31 Aug 2023) · stated 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”
judiciary.uk/…/2023-0315-Response-from-Department-of-Health-and…
What recurred
- 22 Jul 2024 · Omar Ahmed · Graeme Irvine · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.