Steven Jones

Beech Cliffe Limited

Residential Homes for Adults with Autism
Beech Cliffe, Doncaster Road, Rotherham, S65 1NN Tel: 01709 382334 Fax: 01709 382335
Beech Cliffe Grange, Munsbrough Lane, Greasbrough, Rotherham, S61 4NS
Tel: 01709 557000 Fax: 01709 557010

Dear Sir,
Response to Regulation 28 Report to Prevent Future Deaths

We write in response to the Regulation 28 Order made on 14" November 2017, sent on 6 December
2017 to produce a report setting out the actions taken following the death of Steven Jones. We were
granted an extension for our Response to 5 February 2018, for which we are grateful.

Re Record Of Inquest

Before we go on to address the “Matters of Concern” contained within the Regulation 28 Report, we
wanted to set out our position in relation to aspects of Record of Inquest as contained within Box 3
and Box 4,

In Box 3 of the Record of Inquest it was recorded towards the end that “/t is unclear whether failures in
communication and recording together with decisions taken in the care home influenced the outcome.”

In Box 4 of the Record of Inquest it was recorded “Natural Causes in circumstances where it is unclear
whether any deficiencies in care or delays in seeking further medical advice contributed to his death.”

This was not an Article 2 inquest. It was always accepted by Beech Cliffe Limited that there were
some deficiencies, of the types referred to, in aspects of Steven's care in the period leading up to his
death. What the inquest explored in detail during the course of the evidence was the nature and extent
of the deficiencies and whether, on the balance of probabilities, such deficiencies as were found
caused or contributed to Steven's death.

Whilst the coroner has no power to correct/amend the Record of Inquest, and whilst Beech Cliffe Lid is
unable to challenge the coroner's conclusion by Judicial Review, the statements to the effect that it
was “unclear” whether the deficiencies found influenced the outcome were contrary to the evidence.
The issue of causation was explored carefully and at length. There was no medical evidence to the
effect that any delay by either the care home (or for that matter the hospital) contributed to Steven's
death. There was nothing “unclear” or “uncertain” about that evidence. On the contrary, Professor
gave evidence that a life saving diagnosis could only have been made with a CT scan. Dr
im evidence, supported by Professor] was that he wouldn't have ordered one even if he
had seen Steven on 28 November 2013. In so far as is it necessary and appropriate for Beech Cliffe
Ltd to do so at any later date, they will rely on the evidence given at the inquest by _
Professor gjand MiB to show that causation was not established. What the Record of
Inquest might have said, particularly in an Article 2 inquest, was that “....it is possible that [the
identified failures] contributed to the death”. The wording of the Record of Inquest as it is leaves
apparent ambiguity on the issue, when the evidence heard makes it clear that causation was not
established on the balance of probabilities.

Paul & Sarah Ratcliffe
Registered Office: Beech Cliffe Grange, Munsbrough Lane, Greasbrough, Rotherham S61 4NS

Registered Company Number 4075104 - .
ita | Member

Re Regulation 28 Report

In addition to being dissatisfied these aspects of the wording of Record of Inquest as set out above,
we were disappointed and surprised at the statement made by the coroner at the conclusion of the
inquest that he would be making a Regulation 28 Report, given that all of the “Matters of Concern”
were actually dealt with in the evidence given by Sarah and Paul Ratcliffe during the Inquest hearing.
No indication as to any ongoing concern was expressed to either witness during the course of their
evidence. To the contrary every indication was given that the coroner was satisfied with the evidence,
given both orally and as contained with these witnesses very detailed witness statements, as to steps
taken since the death and in response to the identified deficiencies.

An Interested Persons wish to challenge a PFD ruling has been considered in a recent decision of the
Administrative Court, in the matter of R (Dr Siddiqi and Dr Paeprer-Rohricht) v Assistant Coroner for
East London Admin Court CO/2892/2017 (28 September 2017). The judicial review application was
dismissed, finding that a coroner has no power to withdraw a PED report once it has been made. The
Court found that the appropriate measure to challenge a PFD report was through the right conferred
by 7 (2) of schedule 5 CJA 2009, to make a written response.

It is in the light of that decision that our written response is given.

Each of the Coroner's “Matters of Concern” are set out in italics, and our response to each is set out
immediately thereafter.

(1) Although a system of written recording was in place, concerns of carers were not emphasised
nor escalated to seniors either through incident reports or verbally so that opportunities to
initiate full investigations by seniors and/or managers were lost.

Clifton Samuel 'Sam' was one of Steven's one to one carers; he gave evidence at the Inquest
on 7 November 2017 that he was able to raise concerns and that had he done so these would
have been documented.

Steven's other one to one carer, Clifford Moxon also gave evidence to the Inquest on 7
November 2017. He said that he would go to a senior with any problems and if they had not
dealt with it, he would take it higher to a Head of Care. He confirmed to the inquest that in the
relevant period, he never had occasion to escalate any concerns. Clifford accepted in his
evidence to the Inquest that he could have completed an incident report form or mentioned
any concerns in the handover notes and did not do so.

In evidence to the Inquest on 9 November 2017 Sarah Ratcliffe said that if Staff had reported
concerns about Steven's symptoms on Saturday 7 December 2013 then she would have
taken Steven to the walk in centre in Rotherham. Hicave evidence that any concerns staff
had about Steven were never raised with her and neither was she aware of any gossip or tittle
tattle.

In her statement dated 4 October 2017 at paragraph 29 Sarah states that any concerns raised
by staff about Steven's health and well-being should have been documented and would have
been taken seriously, investigated and acted upon.

After Steven's death we became aware of concerns that other members of staff had but had
failed to report, record or act upon. Had we been made aware of these concerns at the time
we would have sought immediate medical assistance.

The night staff failed to report behavioural issues. These issues were not explored in detail at
the Inquest, if they had been Sarah and/or Paul would have explained that in February 2014
they introduced a "traffic light " mood and behaviour monitoring system that the day staff were
already using. Paul explained to all night staff that if the resident was awake at night then their
mood should be recorded on their night report. Amber behaviour was the trigger for an
incident report to be submitted; any behavioural issues would therefore have triggered an
incident report which would be seen the next morning by all managers.

In June 2014 the Anticipatory HealthCare Calendar (AHCC) was introduced [IE aised the
introduction of this system in her evidence to the Inquest on 9 November 2017. This is a NHS
proforma that acts as a criteria-referenced monitoring system for health-related issues in those
with tearning disabilities. Specific symptoms are listed and given a risk level of Green, Amber
or Red; amber and red directly link to required specific staff actions and responses, which are
described within the too! and recorded on a Significant Communication Sheet, part of the
tool. These range from continued monitoring, through administering pain relief or attending a
GP surgery when possible, to contacting emergency services immediately. AHCC is a carer-
level too! that is directive in terms of response to specific symptoms. All staff were trained in
2014 how to use it and it forms part of the induction process for all new staff.

Use of the AHCC is audited on a weekly basis, this highlights any remedial training needs and
ensures the accuracy of the system is maximised.

In 2016 we piloted a new daily reporting system which incorporates another NHS system, the
Disability Distress Assessment Tool (DisDAT). This is another criteria-referenced behaviour
monitoring tool and again links to pain identification and prompts staff to complete behaviour
monitoring forms on every occasion when a baseline of “no concerning behaviours seen” is
changed. The system is designed as an aide memoire, prompting staff to ensure that any
reporting relating to health or other issues has been carried out. We rolled DisDAT out fully at
the staff meeting on 17 November 2017. Neither the Coroner nor the Interested Parties
explored these issues with Paul and / or Sarah at the Inquest so it was not apparent it was in
the scope.

(2)

(3)

Staff did not appreciate the importance of incident reports and that such reports emphasised
illness.

No evidence was heard that staff did not think incident reports were to include illness. Paul
gave evidence to the Inquest on 8 November 2017 that all staff were trained in the completion
of incident report forms, which included for illness and when behaviour went from green to
amber or to red on the traffic light system. Paul told the Inquest that staff had all completed
these forms before, it is not clear why they did not do so in this period for Steven|itold
the Inquest on 9 November 2017 that staff had been trained on the completion of incident
report forms and had completed them on previous occasions for different behaviours.

Paul gave evidence at the inquest on 8 November 2017 that he was surprised that no incident
report forms reporting health issues were raised and that he would have expected staff
working with Steven or the night staff to do so if they had reason to believe he was ill. Paul
also confirmed that the completed forms were put in the Heads of Care Office and he would
pick them up periodically throughout the day, so within several hours of one being generated.

The night staff now use the DisDAT scale described in the response at (1) above to provide a
consistent reporting standard over a 24 hour period.

The AHCC system also removes any confusion about incident reporting, which now relates to
purely behavioural issues, although this does not ignore the fact that pain may be a trigger for
behavioural concerns. Incident Report forms are completed for behavioural issues. We have
body charts to record injury. If a resident vomited faecal matter now this would be recorded on
a body chart and detailed in a Significant Communications Sheet.

In practice staff did not act directly in dealing with illness of a resident, rather channelling
medical issues through the registered managers.

All staff had full first aid training, which includes advising them to call an ambulance in an
emergency. Sarah gave evidence to the Inquest on 9 November 2017 that all staff have
responsibility to meet the needs of residents and all have authority to contact Doctors etc and
all telephone numbers are and were kept in a directory in the staff office, there was no need to
go up the ladder for approval before the cal! could be made.

Paul gave evidence to the Inquest on 8 November 2017 that all staff were trained in First Aid
and trained to call an ambulance in an emergency, this was not a decision that had to go up
the ladder first.

Various members of staff gave evidence that staff below the managers felt free to raise issues
regarding health care with their supervisor who would action as appropriate and that staff felt
free to escalate matters or challenge decisions if they thought necessary.

As per Sarah's evidence on 9 November 2017, staff on shift should have made arrangements
to see the relevant health practitioner, if there were circumstances where they felt Steven
needed medica! attention. The head of care, staff and the named carer all worked as a team
to ensure the resident accessed that health appointment.

Sarah confirmed to the Inquest on 9 November 2017 that it was always decided in advance
who is best placed to take a resident to an appointment. It would always be a named carer so
that the resident was directly supported by someone they knew and were familiar with as well
as a senior carer/manager or head of care.

The introduction of AHCC in June 2014 highlighted the responsibility staff have in acting on
health related concerns. The criteria referenced system and specific actions linked to specific
symptoms and risk levels provides a clear guide for direct care staff to act appropriately.

(4) On the occasion of a serious incident of faecal vomit, staff did not assume responsibility for
calling emergency services but telephoned the registered managers who in turn did not
appreciate the seriousness of the situation resulting in a delay in transferring the resident to
hospital.

On 7 November 2017 the Inquest heard evidence ror (Ne'e Hayward) that she
was the Senior on duty toa the Inquest that on the morning of 8 December 2013 Clare
Gray reported to her that Steven had vomited faeces. Kelly explained to the Inquest that she
made sure that Steven was ok and contacteqiito relay what had happened Jjcave
evidence that she could not say for sure if Steven had vomited faeces or if he had passed a
bowel motion and then eaten it; the latter had happened previously. The Coroner did not
explore this further.

We xpiainea to the Inquest on 7 November 2017 that in any event she did not call an
ambulance immediately because she had checked Steven and he seemed fine and was not
distressed. Certainly this was the impression Paul had when he arrived. In his evidence to the
Inquest on 8 November 2017 he described Steven as being calm and sat on a bean bag. He
said Steven was not distressed or in discomfort.

With the assistance of Sam, Steven's one to one carer MM used the work vehicle to take
Steven to the hospital.

The Inquest heard evidence on 9 November 2017 rom who confirmed that in an
emergency situation staff should phone for an ambulance, indeed staff had done so before.

In his evidence to the Inquest on 9 November 2017 wr accepted that calling 999
would not have necessarily meant that an ambulance was immediately dispatched, even if the
call had been logged as a high priority, which it would not necessarily be.

Should another urgent situation arise, staff would be directed by the AHCC to contact the
emergency services and attend A&E.

In the case of a non-verbal resident with serious problems very early referral to a general
practitioner was not made and when made the resident was not present at the consultation
nor was his one to one carer in attendance.

(5,

ps

In evidence to the Inquest on 9 November Sarah confirmed that Monday 25 November 2013
was the first time she was aware of Steven's symptoms, staff had not raised concerns before
hor completed any incident report forms reviewed the records and noted that before a
bout of diarrhoea that morning Steven had not opened his bowels for 3 days, so thought he
possibly had diarrhoea and/or a tummy bug. Sarah therefore asked staff to obtain a stool
sample for testing.

The stool sample did not become available until 27 November 2013 and was taken that day to
the GP bya It was Professo evidence to the Inquest on 8 November 2017 that
the stool sample was taken to the GP in a reasonable time frame and at that time, given
Steven's age, diarrhoea was the most likely cause.

vi confirmed in his evidence to the Inquest on 8 November 2017 that a range of
professional opinion included the view that Steven's treatment by the Home and decision not
to refer him to the GP before 28 November 2013 was reasonable.

As set out at paragraph 17 of her witness statement dated 4 October 2017, paragraph 20 of
her witness statement dated 4 April 2016 and in evidence to the Inquest on 9 November 2017
Sarah did not take Steven to the appointment on 28 November 2013 because she was
concerned that due to his diarrhoea that morning and the unknown result of the stool sample
he could be infectious. Also Steven had previously exhibited anxious and challenging
behaviour at appointments. She explained her reasoning to the c? i! who

to proceed with the appointment. When asked by the Coroner on 8 November 201

confirmed that he could have insisted on seeing Steven either at the GP surgery or at the
Home.

Usually the one to one carer would attend the appointments, this was confirmed in the
evidence of Clifford Moxon on 7 November 2017 who said "check ups at the Doctors me and
Sarah used fo take Steven to the GP surgery in the car."

BB evicence at paragraph 12 of her witness statement dated 4 October 2017 and when
giving evidence to the Inquest on 9 November 2017 was that this was the first time she had

attended an appointment without the resident, it was a one off. Steven was left at the Home
with Clifford, his one to one carer because Sarah considered that this would be the best way
of supporting Steven.

The Health action plans, which are formal records listing a residents’ health appointments and
outcomes, provide evidence of residents always attending GP appointments with either their
key worker or a member of their care support team that know them well. Domiciliary visits by

GP's and other health care professionals will take place when attending the surgery is not
possible, again accompanied by key workers or staff who know the resident well.

Yours sincerely

For and on behalf of Beech Cliffe Ltd