Recurring concern

Failure to provide adequate supervision of care staff

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First reported 30 Aug 2013•Latest report 17 Oct 2024

Definition

What this concern includes

Includes failures of supervision, support or management specifically concerning care staff or carers responsible for delivering care, including inadequate oversight, supervision arrangements or escalation of unsafe practice.

Not included

  • Excludes generic staffing shortages, training or governance deficiencies unless they directly concern supervision or management of care staff.
  • Excludes supervision of clinicians, police call handlers, prisoners, residents or other non-care staff unless the assertion specifically concerns staff delivering care.
  • Excludes failures in the care delivered to a person where no deficiency in care-staff supervision or management is identified.
Reports
15

Distinct published reports

Individual concerns
15

A report can raise multiple concerns

Date range
2013–2024

First to latest report issue date

Stated actions
15

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission4
Department of Health and Social Care2
Alternative Futures Group Limited1
Bedfordshire Hospitals NHS Foundation Trust1
Corbett House Nursing Home1
Greater Manchester Mental Health NHS Foundation Trust1
gtd healthcare1
Herries Lodge1
Homedotcare Limited1
Islington Social Services1
Leeds Teaching Hospitals NHS Trust1
Litch Care Services Limited1
LNT Software1
Mersey Care NHS Foundation Trust1
Milton Keynes University Hospital1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    Leslie Andrew Swindells · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Leslie Andrew Swindells had a complex mental health background and, after his mental health deteriorated, was found unresponsive at home with self-inflicted puncture wounds to the neck. The concerns included assessment by a practitioner with limited mental-health training, lack of appropriate triage and escalation, failure to recognise and mitigate risk, telephone-based assessment, inadequate documentation, and unclear supervision arrangements.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unclear operation of supervision for mental health assistant practitioners

    Wider context from the report

    “4. The evidence was that where GP practices chose to deploy staff with such limited qualifications to see those who needed treatment for their mental health it was essential that all those in the practice understood the limitations of the role and that there was close supervision of the practitioner. 5. The inquest heard that it was envisaged by the practice that the GP on duty would have a supervisory role. However it was unclear how this operated other than by the mental health assistant escalating a concern to the duty GP. ”

    Source location

    Leslie Andrew Swindells · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Cease employing Assistant Practitioners in Mental Health.

    Verbatim wording from the response

    “• Following consultation, on 6th November 2024 the Director of Nursing and Allied Health Professionals made the decision that going forward, Assistant Practitioners in Mental Health would not be employed within gtd. At present, there are no Assistant Practitioners in Mental Health employed by gtd.”

    Source location

    Response from GTD Healthcare
    Page 2 · response
    Published 17 October 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review non-registered practitioner roles, remits, responsibilities, competencies and management systems for safe practice.

    Verbatim wording from the response

    “• As gtd has other Assistant Practitioner roles, we commissioned a review of all non-registered practitioner roles, including their remit and responsibilities, to ensure that all roles have the required competency and management systems in place for safe practice. This review was completed on the 27 November 2024. The policy and subsequent recommendations will be ratified at the Clinical Quality Improvement Group scheduled for 8th January 2025. The outcome and recommendations from the review will be launched on the week commencing the 12th January 2025.”

    Source location

    Response from GTD Healthcare
    Page 2 · response
    Published 17 October 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing access to a GP or Advanced Clinical Practitioner provides supervision and escalation support for Assistant Practitioners in each practice.

    Verbatim wording from the response

    “These Assistant Practitioners were able to work independently of direct supervision for routine mental health reviews, however they were unable to see any new presentations or make any clinical decisions or plans without the agreement of a senior clinician. Therefore, a supervisor had to be readily available and within close proximity to the Assistant Practitioner to provide support. In each practice, gtd ensures that there is always access to a GP or Advanced Clinical Practitioner, should an Assistant Practitioner need to escalate any concerns about a patient.”

    Source location

    Response from GTD Healthcare
    Page 5 · response
    Published 17 October 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Concerns about care and documentation should be addressed by the provider, rather than NHS England or the CQC.

    Verbatim wording from the response

    “Upon review, many concerns fall within the remit of the provider and their responsibility as an employer to meet the fundamental standards set out in Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 17 October 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Clinical responsibility and liability for the assistant practitioner's actions rests with the supervising GP.

    Verbatim wording from the response

    “Practitioners such as the one who saw Mr Swindell’s are not part of a professional /supervisory body.”

    Source location

    Response from DHSC
    Page 3 · response
    Published 17 October 2024

    Open published response
  2. Inner North London

    AI-generated summary

    Rose Mary Hollingworth · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Rose Mary Hollingworth, a frail woman with significant co-morbidities, was found unresponsive at home on 3 January 2022 after a carer left without carrying out welfare checks or providing care. She was admitted to hospital and died the following day from a spontaneous intracerebral haemorrhage. The concerns included failures to provide suitably trained and competent carers, supervise and manage carers, maintain an accurate care and support plan, and monitor the care agency.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to properly supervise and manage carers

    Wider context from the report

    “(2) There was a failure to properly supervise and manage the carers. ”

    Source location

    Rose Mary Hollingworth · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish structured supervision and monitoring of carers through early supervision, electronic attendance checks, care-note audits, training sign-off and response-to-concern meetings.

    Verbatim wording from the response

    “The following is now in place:”

    Source location

    Response from HomeDot Care
    Page 11 · response
    Published 21 March 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    No evidence was found that the concerns identified in the prevention of future death report remain.

    Verbatim wording from the response

    “Given the action already taken by the Commission, we are reassured that HomeDotCare Limited have responded appropriately in response to the death of Rose Hollingworth. We have not seen evidence to suggest the concerns mentioned in section 5 of the regulation 28 report remain.”

    Source location

    Response from Care Quality Commission
    Page 2 · response
    Published 21 March 2024

    Open published response
  3. Worcestershire

    AI-generated summary

    Mr Peter Antony Joseph Pearson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Peter Antony Joseph Pearson died at Worcester Royal Hospital on 6 December 2021 from aspiration pneumonia, which was in all probability acquired while he was resident at Corbett House Nursing Home. Concerns included a delay in calling an ambulance despite his critical condition, incomplete nursing and medication records, failures in oral-cavity checks, shortcomings in management oversight, and an ineffective investigation into his death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure effective supervision of nursing staff

    Wider context from the report

    “(4) Whilst there have been changes to audit practice, including the use of an external auditor it is not apparent that the oversight by senior management of the Registered Manager or DM has changed materially. Nor is it apparent what the current Registered Manager has done to date to improve record keeping and record retention and the supervision of nursing staff. ”

    Source location

    Mr Peter Antony Joseph Pearson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. Sefton St Helens & Knowsley

    AI-generated summary

    Joan RICHARDSON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Joan RICHARDSON, a frail 98-year-old woman living in supported accommodation, became increasingly unwell at home and was admitted to hospital on 4 May 2020. She had pneumonia, a fractured neck of femur and grade 4 sacral pressure wounds, and died in hospital on 18 May 2020. Concerns included failures to escalate her deterioration and pain, incomplete care planning and risk assessments, inadequate pressure-area care and documentation, and inadequate staff training and escalation procedures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate support and supervision of care staff

    Wider context from the report

    “(brief summary of matters of concern) Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;- 1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc. 2. When Joan complained of pain -the matter was not escalated as it should have been. 3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital. 4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment. 5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly. 6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required. ”

    Source location

    Joan RICHARDSON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  5. Manchester City

    AI-generated summary

    Shona Christine Michaela Campbell · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Shona Christine Michaela Campbell, a detained psychiatric patient with a history of self-harm and repeated ligature incidents, was found in cardiac arrest after using a ligature on 12 January 2019 and died in hospital on 14 February 2019. The principal concerns included incomplete and inaccurate clinical and observation records, inadequate communication, patients’ access to ligatures, insufficiently developed risk-management plans, training and staffing deficiencies, and shortcomings in the serious incident investigation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of appropriate clinical supervision of nurses and support workers

    Wider context from the report

    “8. The need for appropriate clinical supervision of nurses and support workers. ”

    Source location

    Shona Christine Michaela Campbell · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report
  6. Sefton, St. Helens and Knowsley

    AI-generated summary

    Pauline BRUMFITT · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Pauline BRUMFITT died on 15 April 2020 after a fall at a care home led to hospital admission and diagnosis of an intracranial bleed. The concerns were that falls risk assessments, prevention measures and referrals were not implemented after her previous falls, and that the incident was not promptly reported or investigated.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delayed staff supervision and discussion of falls prevention

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to Pauline Brumfitt (as stated above) as they should have been. (2) Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take appropriate action to prevent further falls were not taken as they should have been. (3) The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021, appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence. ”

    Source location

    Pauline BRUMFITT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reinforce falls procedures through staff supervision and deliver falls-awareness presentations across the care home, district and national services.

    Verbatim wording from the response

    “As a result of our investigation and the concerns identified once made aware of this inquest, we have taken a number of actions to reinforce our expectations around falls management, transparency and reporting. This has been communicated across all of our services.”

    Source location

    2021-0098-Response-from-Anchor-Hanover-Group-1
    Page 3 · response
    Published 13 April 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing falls-risk, risk-management and governance processes are considered robust, suitable and effective across all registered locations.

    Verbatim wording from the response

    “We are confident that all of our processes and procedures around falls risk, risk management and governance are robust, suitable and continue to work well across all of our registered locations.”

    Source location

    2021-0098-Response-from-Anchor-Hanover-Group-1
    Page 5 · response
    Published 13 April 2021

    Open published response
  7. Manchester West

    AI-generated summary

    Lauren Victoria Finch · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Lauren Victoria Finch, aged 23, died on 24 September 2018 after suspending herself from a bedroom door while detained as a patient at Atherleigh Park Hospital; she suffered a significant brain injury and later died in hospital. The principal concerns included inadequate suicide-risk assessment and review, inappropriate observation levels and practices, failures in the anti-barricade system, and delayed clinical record entries.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of ward supervision to check compliance with the observation policy

    Wider context from the report

    “2. The Deputy Ward Manager on Westleigh Ward at Atherleigh Park Hospital confirmed that she did not and still does not check that observations by staff are being carried out in accordance with the Trust policy, despite accepting that this was her role when the nurse in charge of a shift. Further, the Deputy Manager of Westleigh Ward did not understand the Policy and thought that observations were to be carried out at regular intervals (as referred to above). ”

    Source location

    Lauren Victoria Finch · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Audit electronic observation records monthly and discuss results at the local quality, safety and safeguarding group.

    Verbatim wording from the response

    “observations are in place for the purpose of reducing risk of suicide or self-harm, there is not a predictable pattern of observation that may reduce the risk reducing impact of this intervention. The introduction of e-observations, early next year, will mean that the exact time observations are taken will be immediately populated on the electronic care record. This will mean a regular audit can be obtained to provide assurance that the requirements of the policy have been fulfilled. This audit will be completed each month and the results will be discussed at the local quality safety and safeguarding group for assurance purposes. The introduction of e-observations is a joint undertaking between our Trust and Mersey Care NHS Foundation Trust, with Atherleigh Park targeted as a priority in the rollout of the project.”

    Source location

    2019-0506-Response-from-North-West-Boroughs-Healthcare-NHS-Foundation-Redacted
    Page 2 · response
    Published 14 May 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Support the Deputy Ward Manager’s ongoing policy-compliance reflection and quality-assurance responsibilities through ward-manager supervision.

    Verbatim wording from the response

    “• Following the inquest, the Assistant Clinical Director completed a reflective session with the Deputy Ward Manager in respect of the number of concerns identified. This session included a discussion about the requirements of the policy when completing 10 minute observation checks. The Deputy Ward manager will also attend the refresher training previously described. In addition to this, the new ward manager on Westleigh Ward is supporting this ongoing reflection in supervision to ensure that policies are adhered to, and the Deputy Manager is fulfilling the quality assurance elements of her role.”

    Source location

    2019-0506-Response-from-North-West-Boroughs-Healthcare-NHS-Foundation-Redacted
    Page 2 · response
    Published 14 May 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct regular ward audits of compliance with the observation policy and report findings to the Borough senior leadership team.

    Verbatim wording from the response

    “• Additionally, the operational manager is completing regular audits, in order to identify any gaps in compliance with the policy. A baseline audit was completed in November 2019 and this will be repeated each month. This is reported into the Borough senior leadership team meeting for assurance.”

    Source location

    2019-0506-Response-from-North-West-Boroughs-Healthcare-NHS-Foundation-Redacted
    Page 2 · response
    Published 14 May 2020

    Open published response
  8. Buckinghamshire

    AI-generated summary

    Lewis Daryl COLGAN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Lewis Colgan died immediately at Princes Risborough Station on 15 September 2017 after jumping onto the track in front of a northbound passenger train. Concerns included the robustness of supervision of care coordinators and care teams, continuity of mental health care during staff changes and sickness, the process for overdue Care Programme Approach meetings, and the robustness of the investigation and resulting actions.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of robust supervision within and across care teams, particularly of care coordinator roles and caseloads

    Wider context from the report

    “(1) It was clear from the evidence that the role of the care coordinator is very important in terms of engagement with patients, conducting risk assessments, coordinating necessary or periodic meetings and providing regular input to the care team. In Lewis’ case the evidence indicated that the last care coordinator with conduct of his case had not received supervision, that the caseload was, for a period, incompatible with part time working, and that the frequency of engagement with Lewis had reduced compared with what had occurred in previous years. There were also concerns about upward supervision of the care team during this period. Whilst evidence was given that the supervision arrangements are being addressed, there remain concerns that supervision within teams and cross-supervision between teams, particularly of the critical role and caseload of care coordinator, may still lack robustness. ”

    Source location

    Lewis Daryl COLGAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  9. Manchester City

    AI-generated summary

    Mrs Kathleen Cooper · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs Kathleen Cooper, aged 73, underwent elective sigmoid colectomy and later deteriorated, suffering an intra-operative cardiac arrest during emergency surgery on 11 July 2016. The report identified medical and nursing neglect, including communication and record-keeping failures, inadequate supervision, inaccurate observations and early warning scores, delayed tests and treatment, and failures to escalate deterioration. Concerns also related to out-of-hours and weekend care and the patient-safety impact of split-site hospital arrangements.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Poor ward-level leadership and supervision of nurses

    Wider context from the report

    “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular: - Poor communication by/between clinicians and nurses - Poor record keeping – medical and nursing - Poor leadership/supervision of nurses - Ward/Matron level - Inadequate supervision by on-call consultants of junior colleagues - Incorrectly calculated early warning scores - Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified - Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording) - The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores - Failure to repeat tests such as bloods and to act upon the results accordingly - Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent - Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics) ”

    Source location

    Mrs Kathleen Cooper · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. Shropshire, Telford and Wrekin

    AI-generated summary

    Ivy Rebecca Morris · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Ivy Rebecca Morris was born with severe perinatal hypoxic ischaemic brain damage and died at home on 3 May 2016 after becoming unresponsive during a feed. The report identified concerns about foetal heart monitoring, failures to follow midwifery guidelines, and potential delays relating to episiotomy support. The inquest concluded that appropriate monitoring during the second stage of labour would have prevented her death, according to the supplied text.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure support and supervision for inexperienced midwives performing episiotomy

    Wider context from the report

    “(3) Episiotomy. Infiltration took place which could have led to an episiotomy and delivery within 10 minutes. There was unresolved evidence as to whether an episiotomy was a planned event or a contingency which did not arise. There was though evidence that the midwife who performed the infiltration had not performed an episiotomy since qualification and wished to have support and supervision should one become necessary. Whilst such support and supervision may have been available in this case, in other this could lead to delay. ”

    Source location

    Ivy Rebecca Morris · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026