Donald Clegg

Julie Gonda 
BA (Hons), ACA, Msc – Leadership, Health & Social Care 
Interim Executive Director of Communities & Wellbeing 

Date 
Please ask for  
Direct Line 

4th December 2018 

PRIVATE & CONFIDENTIAL 

Ms. L J Hashmi 

HM Area Coroner 
Greater Manchester North 

Dear Ms. Hashmi, 

Department for  
Communities & Wellbeing  

 – 

Interim Assistant Director  
of Adult Operation 

I am writing in response to your letter dated 9th August 2018. In my response I have included 
an  overview  of  the  discharge  process  from  Killelea,  what  we  are  changing  going  forwards  and 
also  the  rationale  for  the  decision  to  discharge  the  late  Dr  Donald  Clegg  to  a  short  stay 
placement.  

Choices for Living Well bed based (Killelea) discharge process  

Planning for discharge 

Planning for discharge commences upon a customer’s admission to Killelea. 

The MDT works closely with customers to facilitate safe and timely discharges from the Choices 
for Living Well bed based service.  

The decision to discharge  

The decision to discharge a customer is made as an MDT, and involving the customer / family. 

Where a customer has been assessed as lacking the mental capacity to make a decision about 
discharge, the decision to discharge and discharge destination are made as a Best Interests 
decision.  

For customers who have completed their period of rehabilitation or who are not able / unwilling 
to participate in rehabilitation a decision to discharge to an alternative setting will be made if 
they are not ready to return home.  

    Electronic or fax service of Legal documents is not accepted 

Killelea, Brandlesholme Road, Bury BL8 1JJ 
www.bury.gov.uk 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 For customers show are awaiting a package of home care, they may require a transfer to a 
short stay setting in the interim, as there is often is a high demand for beds at Killelea e.g. 
customers awaiting discharge form hospital. This decision is made as an MDT and professional 
rationale for not transferring to an interim bed are considered on a case by case basis by the 
management team e.g. customers with dementia, who may find an additional move unsettling.  

The following actions are completed prior to discharge: 

Therapy staff confirm that equipment and adaptations that are essential for discharge are in 
place  

Transport arrangements are made – these may be with family/ friends, or depending on moving 
and handling needs, a wheel chair taxi or hospital transport may be required. 

Date and time of discharge agreed with the customer and family 

If the customer is to have a formal package of care at home or is transferring to a short stay 
setting or residential care, the date and time of discharge is agreed with all parties 

Arrangements are made for discharge of medications, and ensuring the appropriate 
documentation is taken with the customer e.g DNAR/ District Nurse file.  

Handover of information/ transfer of care: 

GP, Chemist, District Nursing team, Continence Team, other involved services are informed of 
the discharge time and date  

Onward referrals are made e.g. to the District nursing team to order pressure relieving 
equipment. Contact is made to ensure that the appropriate pressure  

relieving equipment is in place e.g. air flow mattress prior to discharging the customer home/ 
alternative setting to help ensure a safe discharge.  

For customers having local authority commissioned support at home: 

Relevant information form the support plan is shared by the Brokerage team with care providers 
prior to discharge 

For complex cases – care providers are encouraged to attend a moving and handling handover 
discussion with the therapy staff at Killelea  

The care agency/ setting is provided with contact telephone numbers for the Connect and Direct 
(CAD) Hub and the Out of Hours service.  

Electronic or fax service of Legal documents is not accepted 

Killelea, Brandlesholme Road, Bury BL8 1JJ 
www.bury.gov.uk 

 
 
 
 
 
 
 
 
 
 
 For customers having local author commissioned placement in a short stay setting, residential 
care or nursing care: 

For complex cases – care providers are encouraged to attend a moving and handling handover 
discussion with the therapy staff at Killelea  

Arrangements are made for the provider to visit to complete their own assessment, as part of 
their admissions process 

For providers who accept referrals over the telephone, a copy of the social care assessment and 
support plan will be provided prior to admission  

The care agency/ setting is provided with contact telephone numbers for the Connect and Direct 
(CAD) Hub and the Out of Hours service.  

For customers with complex health needs: 

Continuing Health Care screening is completed by the MDT at Killelea and assessments/ reports 
are requested from the District Nursing Team / Consultant Geriatrician to provide evidence for 
funding appropriate support for such customers , for example ‘Fast Track’ funding for a nursing 
placement.  

For customers having a privately arranged package of support / placement: 

Arrangements are made with the provider to visit and complete their own assessment  

A copy of the social care assessment completed at Killelea is made available  

The customer/ family is made aware of their right to a review from the local authority as 
required by the Care Act 2014 

The care agency/ setting is provided with contact numbers for Bury Council should 
circumstances change/ additional input is required  

The care agency/ setting is provided with contact telephone numbers for the Connect and Direct 
(CAD) Hub and the Out of Hours service.  

Following discharge  

Within 24 – 72* hours post discharge (*if discharged prior to the weekend)  

Electronic or fax service of Legal documents is not accepted 

Killelea, Brandlesholme Road, Bury BL8 1JJ 
www.bury.gov.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 A safe and telephone call is made to check that the customer is settling in well back at home / 
care setting  

If any issues have arisen these will be addressed initially by Killelea staff and further action 
taken. This may be a follow up from Killelea staff e.g. a visit , or signposting to another service  

Contact telephone number are shared with customers  and with care providers, The customer/ 
care provider will be notified that their caser will be reassigned to an alternative team for review 
and the contact telephone number for that team will be shared ( as well as the number for 
CAD// Out of Hours) 

Self –discharge  

Occasionally, a customer will decide to self-discharge from Killelea 

A discussion takes place with the customer by a member of staff, to ensure that the customer is 
making an informed decision and to check that they are aware of any risks  

Prior to discharge the customer will be asked to sign a disclaimer form 

The customer is provided with contact telephone numbers for the Connect and Direct (CAD) 
Hub and the Out of Hours service.  

If the customer is assessed as lacking the mental capacity to make this decision, consideration 
is given to where a DOLs application needs to be made. The decision to discharge and discharge 
destination would be made in the customer’s best interest, following the Best Interests process.  

Within 24 – 72* hours post discharge (*if discharged prior to the weekend)  

A safe and telephone call is made to check that the customer is settling in well back at home / 
care setting  

If issues have arisen, Killelea staff will make a professional judgement as to next actions, 
depending on the level of need/ risk e.g. signposting to another service or contacting the 
locality duty team.  

Change to the discharge process  

Following a review of the discharge process from Killelea we have made the following change: 

For customers who are being discharged to a short stay placement at either Elmhurst or Spurr 
House we will arrange to invite Elmhurst or Spurr House staff to attend the discharge planning 
meeting at Killelea, so that they can meet the customer and assess if they are suitable for the 
service. 

Electronic or fax service of Legal documents is not accepted 

Killelea, Brandlesholme Road, Bury BL8 1JJ 
www.bury.gov.uk 

 
 
 
 
 
 
 
 
 
 Rationale for discharging Dr Clegg to a short stay placement  

The allocated social worker for Dr Clegg, 
with Dr Clegg and his son 
arranging for a home care provider to assess Dr Clegg’s needs for a private package of care 

 on the 10 January 2018. The Agreed actions included 

, arranged a discharge planning meeting 

Ms. Barnes contacted a number of home care providers between 10th January and 24th January, 
however none had capacity to arrange to assess at that time, nor to provide a package of home 
care. 

There was a very high demand for beds at this time, from both the hospital and the community. 
When a customer is ready for discharge but there is no support available to enable discharge to 
destination of choice, a move to a short stay placement may be required. 

We have used Elmhurst on many occasions and have considered this to be a safe and 
appropriate placement setting to meet the residential care needs of customers, where a nursing 
placement is not required. 

The proposed move to a short stay placement was discussed with   Dr Clegg and his son on 
24th January 2018 and this discharge arrangement was agreed. 

Ms. Barnes followed the admission process for Elmhurst when booking the placement, and 
liaised with the relevant Occupational Therapist to refer for appropriate pressure equipment and 
ensured that this was in place before the discharge took place. 
 also provided a copy 
of the social care assessment which detailed Dr Clegg‘s needs.  

Yours sincerely, 

Head of Service 

Adult Operations Senior Management Team 

Electronic or fax service of Legal documents is not accepted 

Killelea, Brandlesholme Road, Bury BL8 1JJ 
www.bury.gov.uk

° Persona

We're all about you

28 September 2018

PRIVATE & CONFIDENTIAL

FAO: Mrs L Hashmi, Area Coroner

HM Coroners Court

The Phoenix Centre

L/Cpl Stephen Shaw MC Way

Heywood 91 OC pes

OL10 1LR

Dear Mrs Hashmi,
Regulation 28 Notice - Dr Donald Stuart Clegg (Deceased) - Ref: 64436

I write further to your letter and the Regulation 28 notice in relation to the inquest following
the death of Dr Clegg.

Firstly may I personally express my sadness at the loss of Dr Clegg and I send my sincere
condolences to his family. Secondly.I am disappointed that there are areas of our support
which fell short of the high quality of care that we always aim to provide. I would like to
reassure you that the comments you have raised have been fully considered and it is my
priority that we learn from these and continue to improve our practice. We have a culture
internally of continual improvement and we are not afraid to challenge the way we work. I
have set out some further details below in response to your letter:
Persona and Bury MBC

1. Communication and transfer of care between social services, the first placement and

the final placement

The comments raised relate to the inadequate communication between the care teams at
Killelea (Bury Council) and Elmhurst (Persona), particularly given the complexities of Dr
Clegg’s circumstances.
A meeting has now taken place between the Persona Operations Director and the Business
Manager responsible for Intermediate Managed Care at Bury Council. It has been agreed that
going forward and with immediate effect where a customer is being discharged from Killelea
to Persona services, or vice versa, a representative from Persona will be included in a multi-
disciplinary team meeting with the appropriate health professionals. I will ensure that this is
monitored to see how it works in practice and whether we need to review additional methods
to ensure we have the right level of communications between the respective teams.

Persona Care and Support Ltd
Grundy Centre
Wellington Road
BLO 9AH
0161 253 6000
info@personasupport.org

www.personasupport.org.uk
Company Registration Number: 09725580

Persona

2. The process of assessment of care needs prior to admission was inadequate
The established assessment process within Persona is for a Customer Relations Assistant to
take the initial referral, capturing information via an Initial Assessment proforma. The
Registered Manager would then make a decision on whether they could meet the individual’s
needs and accept the referral, based on the information contained within the Initial
Assessment. I must stress that the Registered Manager or their Deputy are the only
individuals who would make a decision about whether to accept a referral and this would
never be the decision of a junior member of the care or administration team.

In light of the findings from this inquest we have reviewed the assessment process and we
will be enhancing our approach to admissions. . This involves the establishment of an
additional post within our short stay services which will focus on admissions, ensuring that we
obtain detailed information for the Registered Manager to allow them to make an informed
judgement. This will also provide capacity for a face to face assessment or involvement in
multi-disciplinary team meetings (as described at point 1) as required.

3. The Medicine Policy and/or staff training were inadequate and unsafe. The audit
process was perfunctory
As an organisation we are striving for 100% accuracy on our medication management. We
are fully committed to improving our processes and have opened a dialogue with staff to
obtain their views and to review medication management. Throughout the year we have
undertaken a number of different forms of analysis to better understand how and why errors
occur. We have also reviewed the policies, protocols and training that we have in place. We
have found due to the complexity of the services we deliver there is not a “one-size-fits-all
solution” and each service needs a tailored approach. An action plan is currently in place
which we are actively progressing in order to improve performance. By way of summary the
actions taken so far include:
3a. Investment in an Electronic Medication Administration System (EMAR) which is
designed to improve accuracy and safety in respect of medication administration whilst
also improving audit trails. This is being implemented at Elmhurst this week (w/c
24/9/18) and will be rolled out to our other short stay unit Spurr House in October
2018.
3b. On-going exceptional Board reporting on medication errors and. progress against
the medication action plan.
3c. Review and amendment of the medication policy to make it clearer for staff and to
develop visual one page guides on certain key aspects of the policy.
3d. Review of our current medication training which we felt could be improved. We
have therefore sourced an additional detailed and assessed training package which will
be rolled out to staff imminently.
3e. Review and amendment of the self-administration assessments and protocols.
These now include a requirement to count medication weekly for people who are self-
administering, and a mapping tool to allow the amount actually taken to be tracked
against that which should have been consumed.
3f. Development of a comprehensive quality assurance framework (QA Framework).
This has been completed in partnership with an external consultant. The work on the
QA Framework has drawn current audit tools together to ensure that they are fit for
purpose and all audits are meaningful, signed off by a more senior manager, and any
actions are captured at a scheme and organisational level in an Improvement Plan. This
work has taken place across the summer months and is currently being rolled out in

short stay during September and early October. We will work hard as a team to ensure
it is embedded throughout the organisation.

3g. As medication in short stay services is particularly complex and busy we have
reviewed the structure and are currently piloting having a Medication Co-ordinator role
to provide more specialist knowledge and support in this area, as well as additional
skilled capacity to undertake pharmacy and GP liaison and auditing.

3h. Review of the skills required by staff who administer medication has identified that
there are skills around numeracy and attention to detail which had been
underestimated in the previous job description and core attributes. These have now
been added to job descriptions and will form part of the recruitment assessment in the
future.

3i. Focus groups with staff are due to take place in early October 2018 to understand
the challenges that they see in administering medication and any solutions which they
feel would improve their ability to perform consistently well in this area. We are also
talking to other service providers to look at sharing best practice tips and tools.

3j. In addition we have recruited a Compliance Manager (this is a senior appointment)
who will be responsible for auditing medication. This post reports directly to me as the
Managing Director. The post-holder commences on 1 October 2018.

4. Staff were unable to recognise the signs of deterioration and did not seek medical
attention in a timely manner
This finding is one which we have reflected on at some length. As you will be aware,
Elmhurst does not hold a Nursing registration and the staff we employ are social care staff
and not medically qualified. Therefore the monitoring that we undertake when someone is
unwell needs to be appropriate to the specifics of our registration. Having reflected and
reviewed our approach I believe that this service would benefit from additional training
and we also need to empower staff to ask more and better questions of medical
professionals in order to understand what to expect, and what triggers to look for in an
individual’s specific case in order to know when to seek further advice or involve medical
professionals. This is an area that we need to further review and we have added it to our
Improvement Plan and we will be taking it forward during October 2018.

5. Record keeping was inadequate and in parts incomplete

Record keeping in social care has become an increasingly significant part of the role in
recent years and as a result during 2017 we investigated a number of electronic care
planning systems and in autumn 2017 purchased and began implementation of our chosen
system Access Mobizio. Roll-out to Elmhurst took place in February 2018. It is now the
case that all care planning is in the majority digital within short stay. The system allows
real time recording, voice recording and more structured prompts which all contribute to
improved record keeping. The QA Framework includes audits and spot checks of care
records to assess the quality and accuracy of these. We have identified that there is still
further work to do with staff to continue to embed the approach and to drive a culture of
improved record keeping. Part of this process included a series of staff workshops on the
system and on person centred recording in general which took place during August 2018.
Continuing to improve record keeping remains a high priority on our Improvement Plan for
this service. We will look at ways to fully embed this throughout the organisation as we
strongly believe it will significantly help with accuracy of record keeping.

6. There is no policy/protocol for observation/monitoring of service users when directed to
do so by a medical practitioner

Having reviewed this area, we do not have an adequate system and protocol. This links
closely to Point 4 (above). We will be developing a simple protocol for staff and an
appropriate recording system for observations to sit alongside the training mentioned
earlier. The new Compliance Manager will be tasked with this as an urgent action.

Beyond the findings of your report I also wanted to take the opportunity to personally
respond to the comment made about Persona representatives leaving court before the
conclusion of evidence. I apologise on their behalf if this appeared in any way disrespectful or
disinterested. This certainly was not the case and can be explained by the lack of experience
in Coroner’s of Court of these individuals. They believed they had been dismissed from Court
and that it was appropriate for them to leave. We have recently developed a set of guidance
around responding to Inquests, including what to expect when appearing as a witness. We
are also exploring opportunities for Managers to observe cases at Coroners Court to increase
their awareness of Court etiquette and confidence in this arena.

I hope the contents of this letter provides you with satisfactory assurances that as an
organisation, we are actively and continually learning and improving our practices to

safeguard our customers from risk, harm or injury.

In the event, that you require further information or have any follow up questions please do
not hesitate to contact me on or via email at

Yours sincerely

Yesova—

Kat Sowden
Managing Director