Rebecca Gilbank

~~!:~~@ [$TABLE:APP LICA NTS_COMP LETE]~ ~@ [DOC_SECTI ON :APPLICANT D OCUMENTS ]  
~~@[D OC_TYPE: Offer Letter ] 
~~@[AP P_N O: ]~~@ [SU RNAME:Ayton] 
~~@[F ORE NAME:John]~ ~@ [DOC_DATE:  
26/05/ 2016  

]~~ 

2nd Floor, Quadrant House  
31-65 Croydon Road, Caterham 
Surrey CR3 6PB 

t: 01883 331777 
t: 08453 901234 

e:mail@independencehomes.co.uk 
www.independencehomes.co.uk 

19 September 2016 

Dear Ms Crawford 

Inquest touching upon the death of Miss Rebecca Gilbank 
Regulation 28 Report to Prevent Future Deaths 

Introduction 
I refer to the above inquest and your subsequent Report to Prevent Future Deaths dated 
26  July  2016  (the  “Report”).    I  note  that  your  conclusion  at  the  end  of  the  inquest  was 
that  Ms  Gilbank’s  death  was  a  result  of  Natural  Causes  and  that  the  specific  cause  of 
death was Sudden Unexpected Death in Epilepsy. 

Your  Report  contains  two  matters  in  respect of  which  you are  of  the opinion  that  action 
should be taken in order to prevent future deaths and you believe that I have the power 
to take such action.  Please find my response to those two matters below. 

Lack of check at 1.30am on 12 May 2015 
Your  Report  states  “Evidence  at  inquest  revealed  that  the  check  was  not  carried  out 
because  the  two  members  of  waking  night  staff  were  busy  dealing  with  other  service 
users.    The  court  heard  evidence  that  this  was  not  an  isolated  occurrence  and  that 
checks had been missed on other occasions in circumstances in which staff were dealing 
with  other  service  users.    Consideration  should  be  given  to  providing  sufficient  staff 
resources  to  ensure  that  staff  are  able  to  carry  out  the  relevant  checks  at  the  times 
required.” 

It is the responsibility of each local authority to assess individuals in its area who appear 
to  be  in  need  of  care  and  support  and  to  arrange  a  care  and  support  package  which 
meets  those  assessed  needs.    In  the  case  of  individuals  who  are  eligible  for  NHS 
continuing  healthcare,  the  local  authority  should  work  with  the  relevant  clinical 
commissioning  group  (“CCG”).    The  services  provided  by  Independence  Homes  to  Ms 
Gilbank  were  funded  by  Havering  CCG  on the  basis  that  Ms  Gilbank  would  be living in 
her own home Clareville Lodge with two waking night staff on duty each night. A review 
of  the  services  provided  by  Independence  Homes  to  Ms  Gilbank  was  conducted  on 
behalf  of  the  CCG  on  26  February  2014  and  no  issues  were  raised.  Furthermore  no 
concerns were raised by her consultant or GP, who were aware of the staffing levels.  If 

 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ~~!:~~@ [$TABLE:APP LICA NTS_COMP LETE]~ ~@ [DOC_SECTI ON :APPLICANT D OCUMENTS ]  
~~@[D OC_TYPE: Offer Letter ] 
~~@[AP P_N O: ]~~@ [SU RNAME:Ayton] 
~~@[F ORE NAME:John]~ ~@ [DOC_DATE:  
26/05/ 2016  

]~~ 

at any stage any issues had been raised with us as to the staff resources available, we 
would have been happy to discuss provision and funding with the CCG.  I note that none 
of  Independence  Homes’  service  users  receive  funding  for  a  higher  staff  ratio  but  we 
would be happy to provide this at the request of a funding authority. 

Independence  Homes  uses  a  bespoke alarm  system  and  employs  waking  night  staff  at 
each  of  the  locations  at  which  it  provides  its  services.    Depending  on  the  number  of 
service  users  living  at  each  location  and  their  level  of  need,  there  will  be  between  one 
and three waking night staff. As you heard during the inquest, there are two waking night 
staff  at  Clareville  Lodge  between  the  hours of  9:30pm  and  7am. Waking  night  staff  are 
required  to  complete  biometric  night  swipes  every  30  minutes  during  their  shift.  These 
biometric  swipes  ensure  that  the  staff  on  shift  during  the  night  are  awake  on  duty 
overnight.    As  far  as  I  am  aware,  this  goes  well  beyond  the  service  provided  by  other 
specialist  epilepsy  providers,  whose  staff  are  not  required  to  complete  biometric  night 
swipes. 
Independence  Homes  also  has  a  waking  night  manager  (who  works 
approximately  4/5  nights  per  week)  whose  role is  to  advise,  supervise  and  manage  the 
waking  night  domiciliary  care  teams  across  the  locations  that  Independence  Homes 
provides services and to conduct spot checks on services.  Medical and operational staff 
are on call each night.  

There  are  no  guidelines  as  to  how  often  individuals  with  epilepsy  should  be  checked 
during  the  night,  nor  any  guidelines  as  to  how  often  checks  should  be  conducted  in 
connection with the provision of domiciliary care.  However, there is evidence that sleep 
deprivation from sleeping night checks can make seizures worse (as noted in our letter of 
11  April  2014  to  Debbie  Gilbank  and  also  sent  to  the  parents  /  carers  of  other  service 
users).  In general and noting that there is variation in respect of individuals’ care plans, 
Independence  Homes’  service  users  usually  have  checks  which  are  carried  out  by 
waking  night  staff  on  an  hourly  basis.    It  is  not  as  a  result  of  a  legal  requirement  or 
guideline  that  checks  are  carried  out  but  based  on  our  judgement  of  their  care  needs.  
The  purpose of  these  checks is to  check  service  users’ general  wellbeing.   Our  waking 
night staff rely primarily on the bespoke alarm system to detect if a service user suffers a 
seizure.  Waking  night  staff  are  trained  to  respond  to  an  alarm  as  a  priority.    As  noted 
above,  Independence  Homes  has  its  own  bespoke  alarm  system  and  as  far  as  I  am 
aware, this goes well beyond the service provided by other specialist epilepsy providers, 
who  may  either  rely  on  waking  night  staff  or  on  sleeping  night  staff  and  the  benefit  of 
assistive technology. I am unaware of any other service that has waking night staff (each 
of whom is monitored remotely by biometric swipe) as well as bespoke alarms on service 
users’ beds. 

In  terms  of  staff  resources  for  providing  hourly  checks  and  responding  to  other  service 
users’  non-emergency  needs,  there  will  always  be  an  element  of  prioritisation  as  no 
service user receives one to one care at night. While we would expect our waking night 
staff to carry out their scheduled checks wherever possible and in the majority of cases, 
we  accept  that  there  will  be  occasions  where  hourly  checks  will  have  to  be  delayed  or 
missed  where  one  or  both  members  of  staff  are  providing  support  to  another  service 
user(s)  at  that  time.  The  daily  delivery  plan  is  completed  throughout  the  day  and  night 
and  our  processes  require  the  team  supervisor  to  check  it  at  the  end  of  each  shift  to 
ensure  the relevant information  has  been  recorded, including  in  relation  to  checks.  The 
next  morning  it  is  expected  that  the  manager  will  check  the  plan,  which  should  also 
include  consideration  of  whether  checks  have  been  completed.  If  a  check  has  been 
missed or delayed, the manager would be expected to speak to the member of staff and 

 
 
 
 
 
 ~~!:~~@ [$TABLE:APP LICA NTS_COMP LETE]~ ~@ [DOC_SECTI ON :APPLICANT D OCUMENTS ]  
~~@[D OC_TYPE: Offer Letter ] 
~~@[AP P_N O: ]~~@ [SU RNAME:Ayton] 
~~@[F ORE NAME:John]~ ~@ [DOC_DATE:  
26/05/ 2016  

]~~ 

investigate  why  the  check  was  not  completed.  If  an  hourly  check  is  missed  or 
substantially delayed  we  would  expect the  waking  night  staff  member  responsible  to  be 
able  to  provide  an  explanation  as  to  why  that  check  was  missed  and  to  evidence  what 
support  they  were  giving  elsewhere  at  that  time  as  well  as  how  quickly  they  resumed 
checks  thereafter.    In  addition,  a  monthly  quality  assurance  review  is  conducted  by 
Independence  Homes’  Operations  Co-ordinators;  part  of  that  review  involves  checking 
whether  daily  delivery  plans  have  been  delivered  appropriately.  Independence  Homes 
has  also  made  arrangements  for  family  members  of  service  users  to  go  into  services 
once  a  month  to  conduct  spot  checks.  We  note  that  an  alarm  should  always  be 
responded  to  as  a  priority,  even  if  some  form  of  care  or  support  is  being  provided  to 
another service user at that time. 

We  have  considered  the  staff  resources  that  are  available  at  our  services  during  the 
night. We believe that sufficient waking night staff are made available at our services.  If 
an  individual’s  assessed  needs  mean  that  they  require  one  to  one  support  or  a  higher 
ratio of waking night staff to service users, we note that it is the responsibility of the local 
authority  or  CCG  to  arrange  a  care  and  support  package  which  meets  those  assessed 
needs and to fund it appropriately. 

Lack of knowledge about how to obtain an outside telephone line 
Your Report states “Evidence at the inquest revealed that the staff on duty did not know 
how to obtain an outside line to call emergency services and, after trying, had to rely on a 
personal  mobile  phone.    This  resulted  in  a  delay  of  unknown  duration.    Consideration 
should be given to providing clear and accessible guidance to all staff, including staff who 
do not work at Clareville Lodge on a regular basis, to ensure that they are aware of how 
to obtain an outside line in the event of an emergency.” 

I note that, at the time of Ms Gilbank’s death, clear and accessible guidance on how to 
obtain  an  outside  line  was  provided,  I  understand  that  there  was  a  sign  on  the 
noticeboard in the staff office at Clareville Lodge which stated that staff should dial 9 for 
an outside line. 

Independence Homes has taken action in relation to this matter.  At a meeting on 14 July 
2016, at which we considered the evidence provided during the inquest, we immediately 
sought to rectify the issue of  dialling 9 for an outside line from some of our locations.  On 
26 July 2016 we contacted our telephone provider and we  changed our contract so that 
there  is  no  longer  a  need  to  dial  9  to  obtain  an  outside  line.    This  change  was 
communicated  to  staff  verbally,  by  email  on  7  September  2016  and  in  the  Clareville 
Lodge Communications Book.  Please find a copy of the email enclosed. 

Conclusion 
I  hope  that  the  information  in  this  response  provides  assurances  that  Independence 
Homes has taken action, where it has the ability to do so, to prevent future deaths. 

Yours sincerely 

Medical Director