Concerns raised over care staff after 86-year-old’s death
Mr Brown, who required constant one-to-one care due to delirium, passed away in his care home after spending the night asleep on the toilet
Concerns regarding the recruitment and regulation of care staff have been highlighted following the death of 86-year-old Jack Brown in Northamptonshire.
Jack Brown died on 26th January 2023 from ischemic heart disease, as confirmed by a post-mortem examination.
The Northamptonshire resident had been receiving care following a hospital stay for heart failure and hyponatraemia, according to an investigation led by Assistant Coroner Sophie Lomas.
Mr Brown, who required constant one-to-one care due to delirium, passed away in his care home after spending the night asleep on the toilet.
Despite attempts to rouse him, it was only during the morning handover of care staff that his unresponsiveness was identified, and paramedics later confirmed his death.
Regulation concerns over care agencies
During the inquest, which concluded on 24th October 2025, the coroner highlighted serious concerns about the lack of regulation for care agencies supplying staff to care and nursing homes.
Sophie Lomas noted that these agencies are not required to register with the Care Quality Commission (CQC) or any other regulatory body. This absence of oversight means their recruitment practices are unchecked, creating risks to service users' safety.
The coroner emphasised that care homes may rely on agencies to vet carers, leaving them with little oversight of the suitability or training of the individuals hired. Without rigorous checks in place, she warned of the “risk that future deaths could occur.”
Action urged to prevent further risks
In her Regulation 28 report, Assistant Coroner Lomas has called on the Secretary of State for Health and Social Care to address the issue.
She has urged immediate action, placing a 56-day deadline for a response on how these concerns will be tackled. Any response must detail actions or proposed measures along with an implementation timetable.
Copies of the report have also been sent to the Chief Coroner, Jack Brown’s family, and the CQC. The deadline for a response has been set as 13th January 2026.