Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Bridget Gormley · 7 Feb 2023 · David Reid, Worcestershire
“Latimer Court's registered home manager, [REDACTED], conceded in her evidence that neither Mrs. [name redacted] Risk Assessment document, nor her Falls Care plan document were updated following any of these falls”
judiciary.uk/…/bridget-gormley-prevention-of-future-deaths-repo…
What was promised
Stated action 1 · response to Bridget Gormley (7 Feb 2023) · stated timescale: none stated
“Following this very sad incident we have made a number of changes to the provision of care and services at Latimer Court, and these have been adopted across the organisation in other services and divisions where appropriate”
judiciary.uk/…/2023-0114-Response-from-Barchester-Healthcare-.p…
Stated action 2 · response to Bridget Gormley (7 Feb 2023) · stated timescale: none stated
“At Barchester Healthcare, all residents care plans are reviewed by the senior carer in a residential home every month or when anything significant changes in their care or support requirements such as a fall”
judiciary.uk/…/2023-0114-Response-from-Barchester-Healthcare-.p…
Stated action 3 · response to Bridget Gormley (7 Feb 2023) · stated timescale: none stated
“Following any fall or found on floor incident the falls risk assessment should be reviewed and the falls diary completed. The falls care plan should be updated accordingly and referrals made as appropriate”
judiciary.uk/…/2023-0114-Response-from-Barchester-Healthcare-.p…
2 further stated actions are listed on the full chain page.
What recurred
- 27 May 2025 · Keith Inseon · Andrew Cousins · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Bridget Gormley · 7 Feb 2023
“Latimer Court's registered home manager, [REDACTED], conceded in her evidence that neither Mrs. [name redacted] Risk Assessment document, nor her Falls Care plan document were updated following any of these falls”
Later · Keith Inseon · 27 May 2025
“It was noted in the evidence, that the observation scores taken for Mr [name redacted] following his fall had not all been recorded in Mr [name redacted] care notes.”
What happened next
No web check of the stated actions has been published for this chain.