A GRIEVING daughter said it is “hard to accept” that there is no proof the safety lessons promised following the death of her mother have been put into practice.
Clare Gibbs has referred her concerns about a coroner’s report into her mother’s death to an Ombudsman after wishing to see evidence that lessons were learned from the failures in her mum’s care.
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The Prevention of Future Death report found that Jean Waldron received inadequate care from a team leader at Ignite Health and Homecare Services before her death in March 2025.
The 79-year-old had died of natural causes, but Worcestershire coroner David Reid raised concerns that advice was ignored by staff when her pressure sore was inappropriately treated three times.
It was revealed that a specialist district nurse had instructed carers to avoid treating the pressure sore because doing so could have led to adverse complications.
“I want to be clear that the coroner conducted the inquest with care and professionalism, and I am grateful for the time and consideration given to my mother’s case,” said Mrs Gibbs.
“However, I have since learned that the coroner does not have the legal power to verify or audit whether the actions described in a Regulation 28 response have actually been carried out.
“This has been very difficult to accept, as it means that serious concerns can be identified, but there is no mechanism within that process to ensure that lessons have genuinely been learned.
“My priority has always been to ensure that what happened to my mother leads to real change.
“Accountability must be more than words — it must be evidenced in practice.”
Inspections of care services are carried out by the Care Quality Commission, which has shared that it is aware of the coroner’s findings of the Worcester-based care service Ignite Health.
A CQC spokesperson said: “As with all feedback we receive, we use this information to inform our inspection activity and monitoring of services to ensure people are receiving safe care and consider this as part of our incident guidance.”
CQC also revealed that it cannot publicly confirm whether it will inspect a specific service, as all inspections are unannounced.
Coroners Courts have no statutory authority to follow up or ‘enforce’ a Prevention of Future Death Report, and their judicial role ends with its publication.
The Ministry of Justice added that the service is intended to draw attention to risks so others can consider how to address them.
Worcester News has contacted Ignite Health for an updated comment based on Mrs Gibbs claims.
Previously, Andi Williams, operations director at Ignite Health and Homecare Services, said the actions taken by the team leader were an individual decision and not as a result of insufficient training or supervision.
She added that the team lead acted outside authorised duties and Ignite Health will continue to monitor competence through supervision and refresher training.
The agency also claimed it has reinforced existing governance measures by re-emphasising scope-of-practice compliance, escalation pathways, and accountability, particularly for staff in leadership roles.
