I note your request for information was as follows:
Can you please provide details of the actions you have taken to prevent further deaths from the same cause, following the Coroners’ Rule 43 recommendation was made to you in May 2012 which is shown below.
Can you please provide details of outcomes achieved as a result of the actions you have taken to prevent further deaths from the same cause.
The recommendations for your organisation are:
INDEPENDENT SAFEGUARDING AUTHORITY
Recommendation - Published May 2012
To consider a review of communication between care home staff in relation to patient safety and including untoward events which might be relevant to patient care on the accident report form