Overview

• Retired Det Chief Insp Jill Riley told the coroner the inquiry was seriously compromised by delays in reporting bleeding and by missed opportunities to secure evidence.
• Healthcare assistants said they found extensive genital bleeding after death and were told to clean the body, while nurse Matthew Pover admitted he did not escalate the concern and said he failed to grasp its seriousness.
• Investigators found CCTV had been overwritten, the room and bed were cleaned and reused, clothing was destroyed, and medical notes contained significant gaps.
• Home Office pathologist Dr Alison Armour identified a large vaginal wound and concluded the fatal injury occurred at least 48 hours before death during Mrs Kneale’s hospital admission.
• After years of inquiries, including a 2021 arrest later ruled out and separate 2023 convictions for unlawful sedation on the same ward, police say there is not enough evidence to charge anyone and the case sits with the major crime unit.