“A nurse working at Marlborough Court Care Home, who has already been referred to the NMC…”
Dated 2 May 2019, from the coroner for Inner South London. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Report put online after its 56 daysOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
judiciary.uk put this report online on 29 Jul 2019, after the 56 days for replies had ended (27 Jun 2019). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated2 May 2019
- Deadline27 Jun 2019
- Published on judiciary.uk29 Jul 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Nursing and Midwifery Council | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 29 Jul 2019, after the 56 days for replies had ended (27 Jun 2019). These dates can’t tell us whether a reply was due before it went online. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
- A nurse working at Marlborough Court Care Home, who has already been referred to the NMC assessed this frail elderly resident whose leg caused concern to care assistants. In doing so her evidence concerned the coroner was: 1) She found one leg more swollen than the other and of a different temperature but took no action 2) She failed to establish the care assistant’s concern or whether she had met the concern before or after her assessment 3) She failed to measure Vital Signs 4) She failed to escalate to medical care or refer, in the process failed to enable a diagnosis of fractured femur to be made.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2019-0148
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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