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recurance

Dorothy Imisson

5 Apr 2016 · Coroner James Adeley · Preston and West Lancashire

A similar concern from this report was raised again 2 times later. See the linked reports.

The coroner's concerns

  1. 1. lack of care plan

    “No appropriate care plan was developed by the District Nursing Service”
  2. 2. non‑compliance with NMC guidance

    “The District Nursing Service are compromising patient care by not following NMC guidance or record keeping”
  3. 3. non‑compliance with NICE guidelines

    “The District Nursing Services are compromising patient care by not following NICE guidelines”

Linked reports

Raised again laterShannon Quinn6 Sept 2019 · 3 years 5 months later
Closely relatedConfidence 0.80 · moderate

This report

“No appropriate care plan was developed by the District Nursing Service.”

Later report

“There was a lack of a joint multi-disciplinary/Trust care plan and insufficient contact with the care coordinator due to difficulties in travelling to meet the patient outside the normal Trust area and staff sickness absence.”
Original on judiciary.uk ↗
Full chain: Lack of care plan coordination
Raised again laterRonald Nelson15 Jan 2026 · 9 years 9 months later
Closely relatedConfidence 0.90 · high

This report

“(1) No appropriate care plan was developed by the District Nursing Service.”

Later report

“ii) There are concerns over the level of compliance of care plans.”
Original on judiciary.uk ↗
Full chain: Non‑compliance with care plans and insufficient incident review

Responses

No published response was found on judiciary.uk.

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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.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error