Keith Inseon
27 May 2025 · Coroner Andrew Cousins · Blackpool & Fylde
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. inaccurate record keeping with gaps
“the record keeping was inaccurate, contained gaps in the information, and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013”
2. high falls risk
“Mr [name redacted] was at risk of suffering from falls and required an altered diet”
3. aspiration pneumonia following choking
“Mr [name redacted] suffered a choking episode on food. Mr [name redacted] developed aspiration pneumonia and, despite treatment, Mr [name redacted] condition deteriorated and he died”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“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”
This report
“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.”