Ronald Nelson
15 Jan 2026 · Coroner Sarah Wood · Nottingham City and Nottinghamshire
This report repeats 6 earlier warnings. See the linked reports.
The coroner's concerns
1. poor record keeping
“potential issues of poor record keeping”
2. non-compliance of care plans
“concerns over the level of compliance of care plans”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“(1) No appropriate care plan was developed by the District Nursing Service.”
This report
“ii) There are concerns over the level of compliance of care plans.”
Closely relatedConfidence 0.85 · high
Earlier report
“Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr [name redacted] sores”
This report
“There are concerns over the level of compliance of care plans.”
Identical hazardConfidence 0.90 · high
Earlier report
“There were concerns that entries contained in Mr [name redacted] care plan were incorrect, including vital information contained on his weight monitoring sheet. Furthermore, the general quality of record keeping was poor.”
This report
“That there remain potential issues of poor record keeping.”
Identical hazardConfidence 0.90 · high
Earlier report
“(1) The record keeping was inconsistent and lacked detail on general wellbeing.”
This report
“That there remain potential issues of poor record keeping. ii) There are concerns over the level of compliance of care plans”
Closely relatedConfidence 0.90 · high
Earlier report
“Failure to monitor compliance with care plans, and a lack of robust incident”
This report
“There are concerns over the level of compliance of care plans.”
Closely relatedConfidence 0.80 · moderate
Earlier report
“The inquest heard evidence that because Mrs [name redacted] was in a care home setting the District Nurses were responsible for management of her pressure ulcers.”
This report
“ii) There are concerns over the level of compliance of care plans.”