Liam Kenyon

1. 1. lack of clarity regarding care provision and staff interpretation

   “The evidence highlighted a lack of clarity as to the extent of the care provided by the supported housing association and how staff interpret this”

2. 2. failure to conduct hourly checks

   “hourly checks were not conducted on [the deceased]”

3. 3. failure to conduct drug check of room

   “procedure of asking [the deceased] if a drug check of his room could be conducted was not done”

4. 4. failure to update risk assessment

   “risk assessment should have been updated and this was not done”

5. 5. failure to perform welfare check after no response

   “where no response was received a physical welfare check involving 2 members of staff entering the room using the master key should have occurred”

6. 6. deficient serious incident review process

   “the Serious Incident Review process which is in place to learn lessons from such incidents was deficient and ineffective”

No published response was found on judiciary.uk.