1) At Mr Robertson's Inquest, his care notes were referred to and was told that carers were not required to accurately report the time of carrying out checks on him. This meant the Inquest could not accurately ascertain when he had been checked by care staff on the of his death:
2) was also told that whether a resident at Cams Ridge was covered by DNACPR was indicated by a coloured sticker on the door of the resident's room and in centrally-located notes. The sticker on the door was not appreciated by a nurse who attended to when he was found unresponsive and who then went to look in his notes, delaying resuscitation efforts. was told that it would be better if DNACPR status was included on a resident's shift hand over notes which day him would be more quickly accessible than the centrally-located notes
3) was also told that there are no national standards for what should be included in emergency resuscitation packs kept at nursing homes and in consequence, the pack brought to assist Mr Robertson was lacking useful equipment; particularly a suction unit.