John Gwynfryn Morris

CORONER’S OFFICE 
DISTRICT OF HERTFORDSHIRE 

The Old Courthouse, St Albans Road East, Hatfield, Hertfordshire, AL10 0ES 
DX:  100702 Hatfield 
Tel:  01707 292780  Fax:  01707 897399 

MR EDWARD G. THOMAS Senior Coroner  
MR GRAHAM DANBURY, Dr FRANCES CRANFIELD, ALISON GRIEF, EDWARD SOLOMONS  
Assistant Coroners 

11 November 2013  

Compliance Manager  
Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Your Ref: --- 
Our Ref:  3121-2012             

Dear 

Re: John Gwynfryn MORRIS, deceased 
I  am  writing  to  you  under  the  provisions  of  Schedule  5  (paragraph  7)  of  the  Coroners  and 
Justice Act 2009 which came into force in July of this year.  This reenacted the provisions of the 
old  Rule  43  of  the  Coroners  Rules  1984.  Attached  to  this  letter  is  information  concerning  the 
new rules and regulations from which you will see, requires a written response and copies of 
this letter and the response received from you to be forwarded to the other interested persons 
identified  at  the  Inquest  in  accordance  with  the  list  attached.    You  will  note  that  I  am  also 
sending  a  copy  of  this  letter  to  the  Hertfordshire  County  Council  who  were  involved  in  the 
registration of the home as a dementia unit. 

On the 6th November 2013 I concluded an inquest into the tragic death of John Gwynfryn Morris 
(who everybody knew as Gwyn). I have attached a copy of the Inquisition from which you will 
note  that  Gwyn  died  of  1a  Left  ventricular  failure,  1b  Severe  Ischaemic  Heart  Disease  and 
Hypothermia, II Dementia. I recorded a Narrative Verdict and outlined in the circumstances in 
some  detail  the  manner  by  which  he  came  by  his  death.  You  will  note  that  he  suffered  from 
dementia but was described by everyone working in the residential home as a very contented 
pleasant gentleman who liked to help and wander around the unit. Gwyn cared for his wife until 
she  died.  She  also  suffered  from  dementia  but  then,  according  to  his  daughter,  Gwyn  also 
begun to suffer with dementia. He endured distressing placements in Shropshire which was at 
that time his home area. He had been sectioned under the Mental Health Act and the EMI Unit 
to which he was discharged only lasted a very short time. Attempts at looking after him at home 
were unsuccessful and he was moved to Willowthorpe Residential Home, High Street,  

        Cont’d… 

 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
       
 
 
 
 
 
 
 /…. 

Page Two 

   John Gwyn Morris 

Stanstead  Abbotts  Hertfordshire  where  his  daughter  and  the  care  staff  reported  that  he  had 
settled well but that he would wander as Gwyn loved the outdoors. On three occasions he left 
the home, one time walking some six miles to Harlow Railway Station. An Interim Deprivation of 
Liberty Order was made and further security measures were put in place at the home as he had 
escaped through a window. 

Gwyn went missing in the early hours of the 6th December 2012 and as you can see from the 
Record of Inquest, toxicology confirmed therapeutic levels of his medication and therefore it is 
likely  that  he  died  quite  shortly  after  he  left  the  unit.  The  river  Lea  runs  through  Stanstead 
Abbotts very near to the home. An alarm went off on a door when opened earlier but had to be 
deactivated to bring somebody back into the home. On the night he left the home there were 
two staff on duty for twenty four residents. Staff had to deal with a lady who suffered a fall and 
coax Gwyn back in from the enclosed courtyard adjacent to a fire door the alarm of which had 
activated and opened. It appears that that was the door through which Gwyn subsequently left 
the home as all the window locks were found to be secure.  

I  heard  from  a  care  assistant  that  some  of  her  duties  involved  laundry,  setting  tables  for 
breakfast and other tasks that a representative from Hertfordshire County Council described as 
tasks  appropriate  for  domestics.  Staff  both  during  the  day  and  night  need  to  be  able  to  give 
attention  to  residents.  Those  suffering  from  dementia  may  not  sleep  well  and  having  good 
mobility may well be inclined to get up and wander around in their confusion.  

I know that many hospitals are looking carefully at their staffing levels at night particularly in the 
wards where patients suffer from dementia and may be at a risk of falls through wandering and 
I am drawing this case to your attention so that you and your inspectors can look carefully at 
whether  staffing  levels  for  night  time  are  adequate  to  meet  the  various  needs  of  all  the 
residents/patients  in  residential,  nursing  and  hospital  environments.  It  seems  to  me  that  only 
two members of staff caring for over twenty four residents, some of whom suffer from dementia 
and are restless, is not enough to meet all the complex needs, especially with their other duties 
over a long shift of almost twelve hours.  

I  would  look  forward  to  hearing  from  you  in  due  course  and  appreciate  your  interest  in  this 
matter. The schedule requires a response from you within 56 days of receipt which I calculate 
is the week ending 10th January 2014. Please let me know if there are difficulties in complying 
with this timescale or wish to discuss this matter further. I am willing to extend this deadline with 
good reasons. 

Many thanks for your anticipated assistance in this matter, 

Yours sincerely 

Edward Thomas 
H M Coroner

CareQuality
LOmmrsston

Mr E. Thomas
Coroner
Coroner's Office
The Old Courthouse
St Albans  Road  East
Hatfield
Hertfordshire
ALlO OES

16 April2014

Care Quallty commission
Citygate
Gallowgate
Newcastle  upon  Tyne
NE1  4PA

Telephone:  03000 6161 6l
Fa* 03000 616171

www.cqc.org.uk

Care  Quality Commission
Re: The inquest into the death of John Gwynfryn  Morris

Dear  Mr Thomas

We write  in reply to your further letter and to the additional  questions  that you kindly
invited  the Commission to consider and clarifo.

Before addressing  those  questions  we would like to reiterate  our sadness  and great
concern about the issues that were raised in your  report aboui the circumstances
leading to Mr Monis' death. We also wish to emphasise  our very real commitment  to
address  the concerns  raised in your report,  and to assist in improving ihe care
provided not only generally but also with  specific regard to patients living  with
dementia.  We would  also like to apologise  for the delay  in providing our response
which has been  due in part to careful  consideration  being  given  to changes  that  are
currently  taking place  within the Commission  in terms of its structure and the
regulatory  framework  which  underpins the our functions'

In response to your  questions  we attempt  to clariff  our response  as follows:

'1. The Commission  agrees  that the extra  care that is required for people  living
with dementia is sometimes  underestimated  by providers.  The  Commission  is
also very  conscious  of the difficulg in assessing the stafflng needs for people
that live with dementia.  For that reason  when we are inspecting against the
relevant  sfafiing regulationr  we do not only assess  care plan lecords but also . .,.

-  laFfu stailal welrasjatiEntsand-relatfircs-wlrcepossibH\lhen  we inspeci
care plan  records we would  expect to see a care plan for a person's  needs at
night, and particularly  if that person  had been  assessed  as needing  support  at
night. During the course  of an inspection  visit we are only able  to assess  and
track a selection of peoples'  care pathways.  That  does regreftably raise  the

- 

' 

I Regutation 22 ofthe  Healih  and social  care  Act 2008  (Regulated Activities)  Regulations  2010

 possibility that the selection  does  not incorporate.  someone who has cornplex
needs at night.'Hor"uli, as part oi tn" inspection  planning process we do
take into account of intelligence  thaiwLuU ndtp to focus the inspection'  where
the tevets of staffing are raised'  That intelligence
for instance 
would  include ;"y iliif"ttions oi incidents  ol inluries  that providers are
"on""int  "bJut 
well..any concerns..or.complaints  that have been
required to notif,i'tr-  ot, "r 
shared with us, and as a result'of  ri"iting with the local  authority  and the
Ctinical Commissioning GrouP'

'r-;l';-;iri'tOing' 

2. The care  provided  to people that live with dementia  is taken  extrernely
seriously bv tne commissiin. oi""t"r  focus is being  given to the ways in
which  we can i'ipiouu ine Commission's  regulation  of providers that offer care
to people witn iementia. As p"tt oi that-development  between Decernber
2013  and February  2014  atnemei prfq"tt" oiintRection  on the quality  of
care for p"op[: il',ln dementia  t[f-"pf.""..  That. programme  focussed in
pt"pl-"-yt$1t^"T:.ntia  as they move  between
particular on tnJ 
c"r"'not"t.  The programmg  involved inspections of 150
"tp"ti"n""t  91 
hospitals 
in 22 Oitiu*ri  local authorities.  understanding  the
"nO 
hospitals  ano "ar"lor"g 
experience  of peopfe'with  demenii",  tf,"it families and carers has been the
main focus of ihe ieview.  Tne Commiision  is also working  w1h a number  of
dementia org";ir"tions  to help inffi ano improve our approach to regulation
ot iuiiai *orks, what doesn't work and how
by enhan.ing 
dementia care cari be improv"U.  inot" ortanisations  include the Dernentia
Action Alliance, Dementia nOvolacy fl"t*"otL,  Age UK, the Race Equality
local Healthwatch  dS9ryi9s..The  results of that prograrnme
Foundation  "ni 
not only includes  the publication-ot  iiOiuidual  inspection  reports but will also
involve  tne proJuciion'ot a national opoi in May or June 2014 setting  out the
good practice'tnJ'we have fouril'tdgether wjih improvements that can be
made  to dementia  care across diff#;i services'  Consideration of staffing
levels will form part of that report'
rhe Commission  has also sousht  to improve itsoglfl{t:l1"fjfl*l?,::
dementia bY imPlementing Deilrentia  Awareness  Training'  That !raini.n9,  !a1
'Xi;"di#IJ'i""ilitv'";i::-le'.'':-l1T"1":"9:1?S:9
;:ff H?''":t["[i,"iffi 
conr.ifidate  knowredqe.  skills  and support
il1"ji,tTil",i.,TJriotn  ,,"tr to sain 
nf
-^I  ^-r^t^ 
H:?l"y?l'l;r,:d;ilid#ilffiJct  of dementia on o6opre's experience  of
l:^^'  rha+  *raininn haq
i":J"fi Xtl'iffiffi;#^il;'1;t";'i'*qYt1qt.:dvli".'i,ll3l[1':,5?,.*:

^-^arianna 

"no 

3.

and mental  exPerience of those

 4. In terms of night time inspections  the Commission does currently carry  out
inspections  at night if we have a concern about the care  being  provided at
night,  and we will be undertaking more  out-of-hours  inspections  in the future.
Satisfying  ourselves  of the compliance  of a service provider over 24 hours  is
something  that is being  given  careful  consideration  and is likely to change  as
our methodology  changes. Following  the inquest into the tragic death of Mf
Morris,  and the concerns that were raised into  care at night,  an inspection was
undertaken  at WilloMhorpe  Care  Home during  the evening  of 3 March  2014.
The resultant report  was published on 20 March  2014  and can  be found on the
Commission's  website, www.cqc.orq.uk.  For completeness  we enclose  a copy
of that report to this letter. However,  we also  set out the relevant section
dealing with staffing  levels  below:

"Our judgement

'The provider  was meeting  this  standard.

"There  were  enough  qualified,  skilled  and experienced  staff  to meet people's
needs.

"Reasons  for our judgement

We inspected  Vviilov,lthorye because  we had received  concerns  that there
were  insufficient  numbers  of staff available  to meet people's  needs, and keep
people  safe  at night.

"During our inspection on 03 March  2014 we found there were  enough
experienced staff to meet people's needs  at night. Overall we found that there
was a calm atrnosphere  in the home,  buzzers  were answered in a timely
manner  and people were not calling out for help.  Staff  appeared calm and
organised.  There  were  a group of people  still up socialising  in the lounge when
we anived at the home.  People in the residential  unit were able to talk with us
and said they  were happy with the time they  went to bed and were able to
choose when thls was.

'We spoke with two  members  of staff,  two people  who used the service and
looked  at the night care records for two people who used the seruice.  The
manager provided  us with records  of the tnining undeftaken  by two of the
night members of sfaff sobseguent  to our visit. This  demonstrated  to us that
staff had  received  regular  training  in areas such  as moving and handling,
dementia  care, administration of medicines  and  safeguarding.

- . 

---_ 

='---:  netsegi

Willowthorpe provides  care to people  in two separate  units. We found  that

and they were usually suppofted  by an additional  carer  between 4pm and
10pm in the evening.  People we spoke with told us that there were  sufficient
numbers  of staff available  to provide  their  care  and support.

"However,  the provider  may find it useful to note that on the night  of our
inspection one carer had called in sick at shoft notice  and their shift  had not

 been  covered. We looked  at the rotas for the preceding  wegk  and"noted'  this
was a one off occunence.  ii"rl i"  sp2k9 wiih dui1T,,our  inspection  told us
that although they were oiii tn"v ielt they were  able  to support  people's

needs  aPProPiatelY.
"we .ooked at the care records for two  people who used the seruice who  were
at risk of devetoping p,"'"ii-;;'  W" tien checked they received  the care
;r:;;; th;-;;;,;;;inat nai oeen documented  as req'uired' For one person
nad been  plac.ed'on an appropriate  air
who used  the service  *" i'iiinii 
'i;:;;;i;;;  iii  n" i"tt'ne ""  app.ropiate  !?!-t!:,t: 
needs'  However'  we
t.oo high  fo,r 
found for another  person  th;t the sefting  was very  .stightly 
'ih' 
,their
the fotlowins  dav'  Thev totd  us
';;t;',;."w";;"cusiea  trrrs'wiirr 
'"i"gur 
i;;i';i"ii h;;-p*iiiea ru"ii"ii ti inein at handover  and that thev  had
with the carer
adiusted  the setting. fne1-nta is that  they  had .also..spoken 
i;;;r;; ;;; fl;;tr?.""t i"'ti''s" uia nit was to be discussed with  att starr  in
a ieam meeting
"The  two  people's care  records  we looked at identified that they required  two
ilhfi,ipZiiiitii  a,,iiJ i"' iignt . 2t?!^ :?:!:\"d thev checked  and
repositioned  them every tio hoursluing the night' applying  cream to areas
at risk ofpressrre  ,,""'""ii'" Juii ii  peoptfs rooms confirmed that this
tool place.  Staff totd ,t  tnii"tii  ii"". i"'ii\  9't-:y" 
hourtv checks of att
people in the dementia.uiii'a-i'J''ouu  provide supportto  people if this was
required.  slaff we tporu"iiiiniii  u" ihaf thev offered.p"'oPt" !!:k:^:!L
provided personat  care as ieeded'  Records  we looked  at for one peopte
.showed 
of two hourlv checks with
ir"queit nourty checks and care provided'

us that  they h"; ';:;;;  "'-ii'i'u' 

"Aswetouredthebuildingwefoundthatthe.patiodoorleadingtothe.o'utside
from  the lounge on tne ieliita init could be opened  from the inside' we
iii*'iii'i"d'  The stafi  reacted immediately to the
opened the door and ", 
door alarm  sounding and';;;"-;;in';stigate-  We also checked  another door
on the dementia unit ana tiii  nit ii i"  alarmed'  This meant that at night
there were  sufficient numO'ei  of staff  and safety measures  ln place to ensure
'ii"ii'tiiii,ii"i iandering  did not leave the home'"

5. Regrettably, it is extremely  difficuh for the Commission to say definitively
whether  tvvo  memDers ;i ktff ;;'"  sufficient  in numbers  in a unit  where
p"lij" *itii a.t"nti" t""L iesioent n tne circumstances  of this very sad  case'
Those circumst"nt"t  to,iri-i-nJf'le  itte rayout of the home' the needs oJ the
the
service usels at tne noini ai'tne  iime"tne  skills  and experienc€'of 
o'ty  and what tl'" :i?I-t111"j,"::  llY,y:i,:
members  of staff that *"i" 
ffilliffi"d'o;]id;'t#iJ.i: ;Ju" nau".enoeavoured to set out above  we
qre nronosino to oublish t #tLn.ii"port in May or June 2014 whichwiil  s-e1
out t(le geuu Pravrrve 
areful  consideration  of
O" ."OE  lo dementia  care across different  services'  c;
the sufficiency of staffins llt.'G *irr ro- pqt 
9f-111^:^",^t:t-ti::1"11|,';1ll
:F"#ilffi;It:.il?;iy;;"rc  in t"'ttbt  our approach and methodolosv
il ffil"ii"s;rwiJers  tnat care for people  with dementia'

"t 

 We hope that the contents of this letter address the areas on which you sought
further  clarification.  Please  do not hesitate to contact  us if we can be of any further
assistance.

Yours faithfully

<*,|Q."1tl Ca*^"^?lA

Care Quality  Commission-