Curated Topic


Those who work in the NHS have a Duty of Candour, it is enshrined in legislation here (paragraph 20). In a nutshell the duty of candour is a legal duty to be open and honest when things go wrong. Despite sounding incredibly simple, it is in fact exceptionally elusive. What follows are a number of […]

CQC inadequate care for learning disabled and autistic people

Rated inadequate in February 2024 Assure HealthCare Group (South) Ltd, Willow Brook, Fareham (Focused inspection prompted in part due to concerns CQC received regarding a person using the service who sustained a serious injury. This matter is subject to further investigation by CQC. The information shared with CQC indicated potential concerns around the timeliness of […]

CQC outstanding care for learning disabled and autistic people

Rated outstanding in 2024 February Abel Care and Support Ltd, Abel Care and Support Office, Leominster, Herefordshire Consensus Support Services Limited, Kingarth, Manchester January L&Q Living Ltd, East Living Domiciliary Care Services, Stratford Heathcotes Care Limited, Balby, Doncaster (Focused inspection, re-rated from good to outstanding) Rated outstanding in 2023 December St. Anthony Of Padua Community […]

Lacklustre LEDER

LEDER is the name of the Learning Disability Mortality Review Programme introduced in England in 2015. It uses a ridiculous presentation of letters that no-one has ever been able to explain LeDeR. This programme was poorly designed, poorly resourced and poorly led from the outset. A criticism that has been publicly shared by many people. […]


The dictionary definition of neglect is to ‘fail to care for properly’, but things aren’t that straight forward when it comes to legal discussions and coroner’s findings about neglect. What follows are a number of blog posts where I’ve discussed neglect, and how hard it appears to be to find, when discussing the care provided […]

Open Justice

Justice must not just be done, but it must be seen to be done. The principle of Open Justice enables the public to understand and scrutinise the justice system, and it is argued that it is essential to maintaining public confidence in the administration of justice.  Coroner’s courts sit in public and there is always […]

Performative scrutiny

In my WCMT Fellowship report I introduced the concept of performative scrutiny. It seems we’ve reached a point now where there are more investigations happening than ever before, but very little change as a result of them. I can’t help think that this is due to a need to be seen to be responding, rather than getting […]

Social media

I joined Twitter in September 2008 and started blogging shortly after. Without social media I would not have been able to connect, to learn, to campaign or to share court happenings. I’ve co-authored two book chapters with Sara Ryan, about the role of social media in the JusticeforLB campaign: Personal reflections on the #107days campaign […]