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recurance

Beryl Simcock

19 Jul 2022 · Coroner Gordon Clow · Nottinghamshire and Nottingham

The coroner's concerns

  1. 1. lack of written policies for care planning and review

    “I was concerned about the lack of written policies for care planning and review. I was concerned that reviews of care plans and risk assessments were either not done (and the records falsified to suggest that they were) or that they were done by someone unsuited to the task. This was not identified despite audit activity during the relevant period.”
  2. 2. inadequate information to family about deprivation of liberty

    “I was also concerned that at times when Mrs [name redacted] was deprived of her liberty the care home did not ensure that her family were given adequate and timely information to enable them to provide independent scrutiny of the care and restrictions in place”
  3. 3. inadequate review of risk assessments and care plans

    “Taking steps to ensure that risk assessments and care plans are regularly reviewed competently and that the records truly reflect what risk assessments and care plans have taken place”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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