Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate english proficiency hindering communication and safety
The earlier warning
David Sheppard · 8 May 2017 · Louise Hunt, Birmingham and Solihull
“The initial nurse who attended the deceased after the emergency call had poor English and needed to give evidence at the inquest through an interpreter.”
judiciary.uk/prevention-of-future-death-reports/david-sheppard
What was promised
Stated action 1 · response to David Sheppard (8 May 2017) · stated timescale: none stated
“the provider has taken a number of measures to address concerns including, but not limited to, the provision of training with first aid, CPR and choking prioritised in the induction process, as well as documentation training sessions and the introduction of an incident reporting questionnaire”
What recurred
- 9 Apr 2025 · Bernard Lyon · Alison Mutch · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · David Sheppard · 8 May 2017
“The initial nurse who attended the deceased after the emergency call had poor English and needed to give evidence at the inquest through an interpreter.”
Later · Bernard Lyon · 9 Apr 2025
“The home relied on agency staff who the inquest was told struggled to have sufficient grasp of the English language to understand instructions given and to communicate with residents.”
What happened next
No evidence found either way · stated action 1
“Utilize the checklist below to complete your initial incident report.”
[PDF] Choking Incident Report Checklist - NJ.gov · nj.gov/…/choking-checklist.pdf
“FirstAidTraining can teach you to: ✓Identify and treat a choking incident”
First Aid training can teach you to: 1️⃣Identify and treat a ... · facebook.com/…/1390380509940641
No evidence found does not mean the action did not happen.