Joan Rutter

1. 1. inadequate night shift record keeping

   “The standard of the records provided by the rest home were poor. There was a paucity of entries made during the night shift. For example, entries to reflect [the deceased] had been found wandering in the rest home having left her own room were unrecorded.”

2. 2. failure to conduct scheduled night checks

   “Staff were expected to check on [the deceased] at 5am that morning. Having considered the available evidence, the court was unable to conclude that this 5am check did take place. It was s”

3. 3. inadequate supervision of wandering residents

   “The delivery of care during the night shift. [the deceased] was an elderly, vulnerable resident. She was known to be confused, and unlikely to utilize personal alarms, and had a tendency to leave her room. She may have left her room at times when staff were not available to respond to her movement because they were elsewhere in the building. The”

No published response was found on judiciary.uk.