This is a tragic case which highlights the complexity of care for people with dementia and physical care needs and underlines the importance of advance care planning.
CSSIW would like to extend our sincere apologies to Ms A and her family.
We believe there is much to learn from this report and we fully accept its recommendations, many of which have, or are in the process of being addressed. CSSIW implemented new procedures for inspection, enforcement and handling complaints in April 2012 which strengthen the arrangements for assuring the quality of care provided.
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It was a stupid moment of madness that went terribly wrong, said the victim.