1) Agency members of staff on duty did not have any information to assist with the identification of residents. Whilst a system of cards is supposed to operate within the home, the agency staff on duty had no such card to identify residents_ ; J June key

2) Agency members of staff are supposed to have an induction and tour of the home upon their first visit. This did not take place adequately to sufficiently familiarise the staff with the residents or any method of correctly identifying residents_
3) An incorrect file was retrieved resulting in potentially inappropriate treatment of an unconscious resident.
4) The residents rooms are not clearly marked internally or externally to denote who resides in the room giving rise to confusion over identification in the event of emergency treatment being required by an unconscious resident attended to by staff or medical practitioners not familiar with their identity: ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 of the date of this report; namely by 12th March 2015. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain no action is proposed_