Phylliss Letcher

ANSON CARE SERVICES LTD

Registered Care Homes, and Home Care & Support
CARDREW HOUSE - CARDREW WAY

REDRUTH - CORNWALL - TR15 1SP
Telephone: Redruth (01209) 708688

Mr R. Guy Davies

Assistant Coroner for Cornwall & the Isles of Scilly
The New Lodge

Newquay Road

Penmount

TRURO

TR4 9AA

4 October 2018

Dear Mr Davies
Re: Regulation 28 Letter —- To Prevent Future Deaths — Phyllis Letcher, deceased

| am writing in response to your report following the death of Phyllis Margaret Letcher who
died in hospital on 12‘ March 2018, following an unwitnessed fall down eight steps (first floor
to the half landing) sustained at our care home, Crossroads House, Scorrier, Redruth, on 2"
March 2018.

You have raised three matters of concern:

1. The absence of live CCTV monitoring of the stairs and other communal areas.
2. The absence of a key fob restricted access through the stair gate.
3. The absence of an alarm in the event that the stairgate is left open.

Following Mrs Letcher’s devastating fall we were already reviewing whether there could be
anything we might have done differently. Her fall and death shocked us all, and our thoughts
have been very much with her family following this tragic accident.

My response below includes both actions we have taken, including reviewing our existing
service and processes, and also the legislative framework around which care homes must
work in respect of the regulated service we offer.

The three matters of concern you have raised could all impose restrictions on people’s
freedom of movement and freedom not to be subject to continuous supervision and control.
We are obliged to act in accordance with the Mental Capacity Act 2005 (the “MCA”) so we
invited Service Manager for Deprivation of Liberty Safeguards, Cornwall
Council, to visit Crossroads House in order to seek his expertise and advice regarding the
arrangements we already have in place, and to review our processes. We are bound to
consider what would be deemed unlawful restrictions to the liberties of those in our care, and
to carry out risk assessments for those affected. You have seen copies of the risk
assessments carried out in respect of Mrs Letcher.

Anson Care Services Ltd Company No: 10712735 (Registered in England & Wales)
Registered Office: Cardrew House, Cardrew Way, Redruth TR15 1SP

While always balancing risk, the MCA requires us to take the least restrictive measures
necessary, and to consider what the person would lose through whatever measures might
be taken to restrict their activities. It is not about eliminating risk, but is about minimising risk.
We are required to assess the benefit (via risk assessment) of what the person would lose
by whichever measures are put in place. In other words, we are obliged to balance
considerations for a person’s safety against their rights to be free to make decisions for
themselves. If a person has capacity to make a decision, they must be free to do so, even
if we feel that a different decision might be safer or wiser for them.

Often when assessing the care and support needs of an individual, everyday activities are
identified that will benefit their lives, but also put them at some level of risk. This requires a
balanced and proportionate decision to be made between the needs, freedoms and dignity
of the individual and their safety.

The following is taken from the Health and Safety Executive website, risk assessments in
care settings.
(http://Awww.hse.gov.uk/healthservices/sensible-risk-assessment-care-settings. htm)

“Care assessments should enable people to live fulfilled lives safely, rather than be a
mechanism for restricting their reasonable freedoms. Many care providers find it hard
not to slip towards a risk adverse approach for a multitude of reasons, for example,
resources, bad experiences and a fear of the consequences if things go wrong.

HSE will support decisions to allow everyday activities to be undertaken provided a
suitable and sufficient risk assessment has been carried out, documented and
reviewed as necessary. This should identify and implement any sensible precautions
to reduce the risk of significant harm to the individual concerned”

At Crossroads House risk assessments for likely risks are completed for all service users at
the time of admission, and again after a period of observation and familiarisation (and in the
future as necessary if or when needs change). Measures are taken in the best interests of
the person at that time according to identified risks.

In respect of stairs, the HSE sets out the following guidance, about which | have added my
own comments in respect of our care home.
(http:/Avww. hse. gov.uk/healthservices/slips/reducing-risks-stairs.htm )

“Reducing the risk of falls on stairs

HSE is aware of numerous incidents where patients or residents have fallen on stairs,
which have resulted in serious injury or death. There are a number of factors that are
particularly relevant to patients and residents and should be considered in the
individual's care plan.

Stairs should be in safe condition and be of suitable design and dimensions for their
use as set out in Building Requiations Approved Document K

You should consider whether they:
. are well lit; YES

. have handrails at an appropriate height that contrasts with the surroundings;
YES

. have good slip resistance properties, particularly at the leading edge; YES
- carpeted

. have clearly marked edges; Carpeted/Glued down from edge to edge,

and in good condition
. are free from trip hazards or obstacle; YES

If patients or residents lack mobility and require extra support, then the stairs should
have suitable handrails on both sides. Ideally, stairs should not be steep, winding,
curved, nor have open risers. Where individuals are identified as having sight
impairment, and are still allowed to use the stairs, the leading edge of the step should
be marked to improve contrast between the step and edge. (Mrs Letcher had normal
eyesight). These features make the stairs safer for all users, including staff.
Wherever possible, wearing of sensible footwear should be promoted.

Where an individual’s mobility, balance or other conditions puts them at risk of falls,
an assessment should be completed, which can consider whether access to the stairs
is appropriate and under what circumstances. Where they are mobile, but are at risk
of falls, the views of the individual, care professionals and family representatives
should be considered as part of any assessment when deciding whether access to
the stairs is appropriate. Some stairs (e.g. steep cellar stairs) may not be suitable for
use by residents with mobility or balance issues and may present a significant risk.
Where wheelchairs or mobility scooters are used near access points at the tops of
stairs, suitable controls should be put in place to reduce the risk of falls.

Where access needs to be restricted for a few individuals, assessment should identify
what controls need to be in place. This may include:

. keypads on doors; YES, we have these in areas which are further away from
close staffing presence

e emergency release systems (e.g. in the event of fire); YES
° alarms alerting staff to the use of stairs (where staff are always able to respond)
NO

e monitoring of stairs (in case of a fall); NO — but staff are always nearby

Discuss this with a Fire Safety Officer if it impacts on fire evacuation. You may also
need to seek advice on how to prevent access through external fire doors in a way
that they can be released and quickly accessed in the event of fire.”

| believe our practices are largely in line with what the HSE has suggested but also in line
with the MCA. A mental capacity assessment is undertaken for all service users, and for
those found to be lacking the capacity to make specific decisions, the least restrictive
interventions are made along with identifying those risks to which the person might be
exposed, and their rights. It is then our responsibility to balance any restrictions imposed
with any risk, against what benefits would be lost.

The following are excerpts from the Mental Capacity Act 2005 Code of Practice:

“What does ‘lacks capacity’ mean?

One of the most important terms in the Code is ‘a person who lacks capacity’.
Whenever the term ‘a person who lacks capacity’ is used, it means a person
who lacks capacity to make a particular decision or take a particular

action for themselves at the time the decision or action needs to be taken.
This reflects the fact that people may lack capacity to make some decisions
for themselves, but will have capacity to make other decisions. For example,
they may have capacity to make small decisions about everyday issues such

as what to wear or what to eat, but lack capacity to make more complex
decisions about financial matters.”

And further:
“However, as chapter 2 explained, the Act's first key principle is that
people must be assumed to have capacity to make a decision or act
for themselves unless it is established that they lack it. That means
that working out a person’s best interests is only relevant when that
person has been assessed as lacking, or is reasonably believed to lack,
capacity to make the decision in question or give consent to an act
being done.

People with capacity are able to decide for themselves what they
want to do. When they do this, they might choose an option that
other people don’t think is in their best interests. That is their choice
and does not, in itself, mean that they lack capacity to make those
decisions.”

On admission, Mrs Letcher was assessed as having retained sufficient mental capacity to
take responsibility for her own independent mobility around the home at that time. Her care
plan documented that in this setting she was at ‘LOW’ risk of falls and that she was
independently mobile without requiring the use of aids.

She was assessed as capable of holding her own fob with which to open doors where other
service users might require restrictions. She was also found to have retained the ability to
use the telephone in the corridor (one in the corridor of each fob secured bedroom wing) and
to read and understand which number to select to call for support to be ‘let out’ of her corridor
if she happened to have left her fob in her room.

She knew and retained the knowledge of what the fob was for. She could also find her way
independently to her own corridor and identify her own bedroom. She was seen to be
competent at operating the main lift and to finding her way without difficulty between her
bedroom upstairs and the ‘village’ (communal areas) downstairs.

The risk assessments were carried out with the involvement of her family, and the limits to
her restrictions (and freedoms) were implemented with their full agreement.

(Link to further information about responsibilities in respect of the Deprivation of Liberty
Safeguards https://www.scie.org.uk/mca/dols/at-a-glance)

Mrs Letcher’s dementia was sufficiently ‘mild’ to enable her to dress independently but often
without remembering to wash, and to come down, again independently, at different times -
sometimes in the early hours - for breakfast. Staff would subsequently encourage and escort
her back to her room for assisted care for personal hygiene needs after she had
accomplished whatever it might be that she had wanted to achieve downstairs. It was not
unusual for her then to forget she had already had breakfast, and to request, and be given,
another. She settled very quickly in the care home setting and her medication for agitation
and anxiety had been able to be considerably reduced from what had been found necessary
to be administered in her own home. The prescription for Lorazepam was an ‘as necessary’
(PRN) medication, and with the freedom of movement and available distractions and
activities within the larger setting of this care home, her anxieties had significantly diminished.
Lorazepam was therefore only required to be administered five times during her albeit short
time with us. At home | have been given to understand that it was found necessary for her

to receive this several times on most days.

Restricting Mrs Letcher’s movements would have resulted in an increase in agitation and
anxiety, which at home had only been minimised by one to one support from her very caring
family, and by medication. The ‘least restrictive’ option was applied here, in our view correctly,
although we completely accept this lack of constant supervision and sedation will have
contributed to her tragic accident. (However, tragic accidents can also happen in everyday
life to other people too, who do not have dementia.) We would note, however, that it is not
lawful for us to subject people to constant supervision and control where they retain the
mental capacity to make their own decisions and we are not able to impose a best interests
decision on them to subject them to that level of supervision.

My specific responses to your individual concems are as follows:

1. The fall was not seen, although it was heard, and staff attended immediately. It is not
our view that live CCTV monitoring could have prevented this unless all access to the
stairwell was prevented for all service users. This is something that JJ (DoLS
Service Manager, Cornwall County Council) has said should be ‘robustly resisted’. Having
live CCTV coverage would significantly increase the restrictions put on all service users, and
would not be considered ‘necessary or proportionate’ and nor would it respect service users’
rights to privacy and not to be ‘watched’ at all times; it would take away dignity for those who
would therefore be under constant surveillance. If people did not agree to it, it would be a
breach of their right to be free from constant supervision and control.

Live CCTV at all times is also impractical because it would massively increase the costs of
care home placements to all parties, including individuals, the local government and NHS,
while still not necessarily preventing all accidents. | do however plan to see whether the
CCTV coverage in place already (not live) can be extended to cover all levels of the stairwell
so that it can be seen retrospectively exactly what might have led up to any future falls if this
should happen (in communal areas) so that any specific individual cause (or causes) could
be more accurately identified and appropriately minimised if possible for the future. There is
current and ongoing huge national debate about the invasion of privacy with regard to the
use of CCTV monitoring in care homes, and no clear conclusions are yet available. (In our
homes families - with the appropriate consents such as advance directives and Powers of
Attorney for Health and Welfare — are welcome to introduce their own devices into bedrooms
without reference to us.) If people do not want to live in a home that has CCTV, | do not
believe that we will be able to force it upon them (nor would | wish to).

While | can see the benefit of being able to review CCTV footage to ascertain how falls have
occurred after the fact, this particular incident probably would not have been preventable if
watched by staff from afar. Staffing in care homes is constrained by funding. In my view, it
is more useful to have our staff circulating and interacting with our residents so that they can
help to prevent accidents in person than to watch people remotely. Staff often provide
support when a person appears to be ‘wobbly’ or in difficulty. Watching from another room
may help to pinpoint what happened but having staff available in person allows them to
intercede more effectively at the point when a person experiences difficulty.

2. |Wehave considered your concern that we should add key fob access to the stair gates.
We have then considered the consequences if key fob access had been in place at the time
of Mrs Letcher’s admission. Since she had the required mental capacity to make her own
decisions in relation to mobility and transfers, it is highly likely that we would have needed to
provide her with a fob in order to prevent an unlawful restriction on her movements and

deprivation of liberty. This is similar to her use of a walking stick. While she was unsteady
on her feet at times, we were not able to force her to use a mobility aid. An aid had, in fact,
been suggested to her before she came to live in our home, but she refused to use it.
Similarly, we would not have been able to prevent her from using the stairs by refusing to
provide her with a fob, so it is not clear that a fob would have prevented her fall.

There is the further practical complication that such fobs would need to be linked to the fire
alarm system so that they release automatically in the event of a fire. This would require
extensive additional fire cabling supply to each level. Automatic release of fire escape routes
presents its own challenges and risks for people with dementia — especially as the fire alarms
can often be ‘set off by service users with dementia.

We are also concerned that restricting access in this way could lead to other falls where
some agitated service users may attempt to climb over the bannister rails (as has been
ed by staff before with one service user when being escorted to his room).
a: suggested we seek out a different type of latch which would not restrict opening,
ut which would ‘lock’ (latch) shut more easily without displacing the risk elsewhere, meaning
that the gates would automatically close behind the individual.

We also have to consider the fact that the gates would release if service users were to
activate the fire alarms — which certain of them have done very often in the past, meaning
all fob accessible areas will release immediately anyway. We have time delays agreed with
the local fire service in order to minimise the risk of unintended exit from the main entrance
doors only, giving the staff time to respond to the alarms, to check the fire panels, and to
confirm whether this is a false alarm or for real. However, this would still leave the gates
open for a period where the risk to service users would increase as they would have come
to believe they were always fixed in place.

Most care homes have stairs without gates at all; it may be that a further debate is that we
should remove the gates altogether as it is at least a possibility that Mrs Letcher tripped and
fell backwards while attempting to close the gate behind her. Had there been no gate at all,
it is feasible that she may not have turned and fallen backwards. However, this carries with
it other risks.

3. We are looking into whether it is possible to have an alarm which is audible to carers
in and around all areas of the home, and which identifies which gate is open. In the case of
Mrs Letcher, access was only obtained by her and a couple of other residents who had been
assessed as capable of holding a fob, and so this would not have prevented her from having
access herself.

This is the only stair accident that has been sustained. 278 different service users have lived
or stayed in this home over the years since the home first opened in April 2013, and this is
the only accident or near miss on stairs that has happened to a service user. In this time, a
smail number of them have liked to use the stairs as this is what they have always done at
home. If they have appropriate mobility, and the capacity to make this decision for
themselves, we have no right to restrain them.

We very much recognise and regret the distress and grief which the family has suffered due
to Mrs Letcher’s shocking and untimely death, and wish to do anything in our power to avoid
preventable accidents whenever this can be achieved without causing further agitation or
anxiety to people with dementia, nor where this might displace one risk only to increase
another risk elsewhere.

Service Manager for Deprivation of Liberty Safeguards (DoLS)
pwilkins@cornwall.gov.uk has expressed his willingness for you to contact him if you wish
for further information about anything his role and skills might assist with in respect of this.

Yours sincerely,

Managing Director
For Anson Care Services Limited