Terence James

Head Office 

C/O Charing House, Canterbury Street, Gillingham. Kent. ME7 5AY 
Telephone 01634 584600  Fax 01634 584650 

Central & South East Kent Coroners 
Cantium House 
2nd Floor 
Maidstone 
Kent 
ME14 1XD 

By Email and Special Delivery: 
kentandmedwaycoroners@kent.gov.uk  

Dear Sirs 

28 January 2020 

Regulation 29 Response, following inquest touching on the death of Mr Terrance Ewart James 

I  am  the  Director  for  Care  and  Operations  for  Charing  Healthcare,  a  group  of  Care  Homes 
within  Kent  and  Medway.    I  have  worked  with  the  group  for  the  past  11  years,  previously 
having worked with KCC for 20 years within the social care sector. 

I attended the inquest into the death of Mr James and have also investigated the coroner’s 
Regulation 28 report. I write to provide you with my response in this respect. 

I have sought to address each issue raised below: 

1.  The GP was due to attend Mr James on 17 April and was not informed of his fall prior 
to  his  attendance.    He  had  bruising  and  abrasion  to  his  head  and  was  on 
anticoagulation  medication.    The  GP  examined  him  and  found  no  apparent 
neurological symptoms or fracture.  He advised that if there was any deterioration to 
seek further urgent advice.  The GP evidence was that he would have advised that Mr 
James be taken to hospital  

We have a clear process in place in relation to escalating matters to the GP.  Essentially, the 
senior  on-duty  in  the  morning  calls  the  surgery every morning  with  a  list  of  residents  that 
need to be seen.  The GP then attends the home after his/her morning surgery usually after 
1pm .  This is normal practice, and the process used by most care homes in conjunction with 

____________________________________________________________________________________________________ 

A member of Charing HealthCare Group 
Company Registration No:5124236 

                                         
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Head Office 

C/O Charing House, Canterbury Street, Gillingham. Kent. ME7 5AY 
Telephone 01634 584600  Fax 01634 584650 

their  associated  GP  surgery.    Furthermore,  we  are  not  able  to  unilaterally  change  this 
process, as it is driven by national GP arrangements  

On  this  particular  occasion,  Mr  James  was  already  on  the  list  to  be  seen  by  the  GP,  for 
another concern.  Therefore, there was no reason to put him on the list following the fall, as 
he was already on the list and there was no immediate concern at that time because he had 
got himself up from the floor and back into bed.  The GP would not come out earlier in these 
circumstances, as the GP has to attend to the patients in the surgery before coming out to 
the home.  The only other option would have been to escalate the incident to an emergency 
and call 999.  This fall was not deemed to be an emergency, and the GP also confirmed that 
Mr James did not require urgent intervention when he attended.  As an organisation, we are 
under  a  duty  not  to  escalate  the  matter  unnecessarily,  as  this  inevitably  places  further 
pressure on emergency services.   

Number (1) quoted above refers to the GP advising that any deterioration required further 
urgent advice.  Our understanding of the advice is that this referred to a deterioration in Mr 
James’  condition,  however,  there  did  not  appear  to  be  a  deterioration  in  his  condition, 
rather Mr James had a further fall, which has been addressed below. 

2.  The history of the fall on 17 April was not handed over to  care staff who had returned 

from leave on 20 April. 

In accordance with the court’s request, we did set out in detail our practices in relation to 
handover,  in  our  letter  to  the  Coroner  dated  12  December  2019,  and  this  is  summarised 
below: 

Prior to adopting an electronic system for care planning, monitoring and handovers, Charing 
Dale  Limited  used  paper  based  ‘handover  sheets’.    The  paper  based  system  used  to  be 
standard practice in all of the Group’s Homes.  This pro forma enables all staff to quickly see 
any issues that have arisen, and which residents need extra monitoring.   

We moved to an electronic system in April 2019.  We adopted the electronic system for a 
number of reasons, including the Care Quality Commission’s guidance in relation to moving 
forward  with  regards  to  technology.    The  benefit  of  the  electronic  system  is  that  it  is 
completed  at  the  time  care  is  delivered  and  can  incorporate  a  lot  of  information.    It  is 
difficult to demonstrate this in court due to the fact that the system is designed to enable 
access to the information electronically.   

____________________________________________________________________________________________________ 

A member of Charing HealthCare Group 
Company Registration No:5124236 

                                         
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Head Office 

C/O Charing House, Canterbury Street, Gillingham. Kent. ME7 5AY 
Telephone 01634 584600  Fax 01634 584650 

However, due to the concerns raised by the Coroner, we are conducting a full review of our 
handover system.  For the time being, we have reverted back to the paper based system for 
handovers, across all of our homes as it is a visual tool that can be read straight away rather 
than having to find the appropriate tab on a system to read back in the notes.  The system 
was  put  in  place  at  Chippendayle  Lodge  immediately  after  the  inquest  on  11  December 
2019.  It was communicated to staff in internal meetings, and we are ensuring that all staff 
understand  the  importance  of  ensuring  the  handover  forms  are  completed  in  full.    This  is 
being done through team meetings, which have taken place, for example, on 11 December 
2019 and 13 December 2019. 

With regards to the senior carers communicating between shifts, there is a book in place for 
this purpose.  In addition, we now have a full and comprehensive handover sheet that will 
in  the  folder  for  two  weeks  for  all  staff  to  read  to  avoid  any  future 
remain 
miscommunications.    All  seniors  sign  the  handover  sheet  over  to  the  next  shift  senior  as 
evidence  they  have  read  it.  We  are  ensuring  that  all  staff  appreciates  the  importance  of 
completing the paperwork fully and in a timely manner.  This will be monitored closely and 
any  concerns  addressed  with  the  relevant  staff  on  an  on-going  basis.    As  indicated  above, 
this was implemented straight after the inquest, on 11 December 2019.   

A further staff meeting was held on Friday, 13 December 2019, and the manager shared the 
details  of  the  inquest  to  ensure  that  all  staff  understood  the  importance  of  following  the 
systems and protocols in place and to enforce expectations in this respect.   

Furthermore,  due  to  the  concerns  raised  by  the  Coroner,  we  are  implementing  this  paper 
based  system  in  all  of  our  Homes.    All  managers  were  notified  of  the  change  on  13th 
December  by  email.  It  was  difficult  to  demonstrate  how  the  electronic  system  worked  in 
court but it does have some helpful and positive additions.   However, whilst we conduct a 
comprehensive  review  of  the  handover  system, we  will  ensure that  all  our  Homes  use  the 
traditional paper based approach. At present, we are using both methods for handover, and 
it is likely this will remain a long term arrangement. We have a managers meeting on 29th 
January and I will be asking managers for feedback on the current arrangements.  

The  outcome  of  the  inquest  has  been  shared  with  the  managers  at  all  of  our  Homes  as  a 
learning opportunity.  This took place on 13th December and we will also discuss it on 29th 
January at the manager’s meeting. 

____________________________________________________________________________________________________ 

A member of Charing HealthCare Group 
Company Registration No:5124236 

                                         
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Head Office 

C/O Charing House, Canterbury Street, Gillingham. Kent. ME7 5AY 
Telephone 01634 584600  Fax 01634 584650 

3.  A chiropodist raised concerns on 18 April that Mr James was in pain and this was not 

escalated for further medical advice. 

We do have processes in place in relation to professional visits.  We have an electronic care 
plan system where visits are logged.  We have also retained some communication sheets so 
that professionals are able to write the notes up for each person they visit.   

We  understand  there  is  a  factual  dispute  regarding  whether  the  chiropodist  did  raise 
concerns and who these concerns were raised with.  Our records document the chiropodist’s 
visit,  but  do  not  indicate  concerns  were  raised  and  the  chiropodist  was  not  called  to  give 
evidence at the inquest to ask further detail in this respect.   

4.  Mr  James  sustained  a  further  unwitnessed  fall  at  approximately  10:25  on  20  April.  
This fall was not escalated for further medical advice until after a change of shift at 
19:00 when his deterioration was immediately noted and escalated. 

We have policies in place in relation to escalation.  All staffs know that any concerns should 
be escalated to either the relevant member of staff on-call or to the Care Home Manager, 
who  can  be  contacted  at  any  time  of  day  or  night.    This  issue  related  to  an  individual 
member of staff making an incorrect judgment call.  The staff member on duty did seek to 
address the matter, but relied too heavily on discussing the matter with the family, who had 
a POA health and welfare, rather than using her professional judgment.  The staff member 
has  received  further  training  and  the  issues  raised  at  the  inquest  have  been  discussed  in 
depth  with  her.    She  very  much  understands  the  importance  of  ensuring  escalation  is 
immediate.  In addition, as outlined above, the outcome of the inquest and concerns in this 
respect have already been shared throughout the organisation. 

Furthermore,  all  these  processes  and  procedures  have  been  recommunicated  to  staff  in 
team  meetings  and  supervision  sessions.    These  have  taken  place  across  the  board,  and 
many had taken place before receipt of the Regulation 28 report, within hours of the inquest 
taking place. 

As  an  organisation,  we  also  conduct  regular  audits.    We  have  a  schedule  in  place  in  this 
respect. We are also in the process of introducing a specific audit  relating to the handover 
process, and this will be in place from  29 January 2020, after the managers’ meeting, where 
it  will  be  discussed.  We  have  endeavoured  to  put  robust  systems  in  place  to  ensure  that 
errors do not occur again.  The above being said, we had in fact put a great deal of thought 

____________________________________________________________________________________________________ 

A member of Charing HealthCare Group 
Company Registration No:5124236 

                                         
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Head Office 

C/O Charing House, Canterbury Street, Gillingham. Kent. ME7 5AY 
Telephone 01634 584600  Fax 01634 584650 

into  the  processes  in  place  before  the  inquest,  and  we  do  believe  that  where  errors 
occurred, they were individual judgment calls, rather than systemic errors.   

We take these matters extremely seriously.  For this reason, both the care home manager 
and I (Director of Care and Operations) were present throughout the inquest in case there 
were any systemic issues that needed to be addressed.  However, despite our attendance, 
no-one was asked to give evidence on behalf of the organisation, and we had no opportunity 
to set out our processes in place in respect of these issues.  

In  any event,  we  are  always  keen  to  review  and  revise  our  policies  and  procedures  where 
appropriate  and  we  do  conduct  systematic  and  rolling  reviews  as  an  organisation.  
Therefore,  we  have  ensured  robust  systems  are  in  place  and  that  these  have  been  fully 
reviewed, and updated accordingly. 

Yours faithfully  

Director of Care and Operations 
On behalf of Charing Dale Limited 

____________________________________________________________________________________________________ 

A member of Charing HealthCare Group 
Company Registration No:5124236