Anthony Slack

HSCA Further Information 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Telephone: 
Fax: 03000 616171 

Alison Mutch  
HM Senior Coroner 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

Via email: 

04 February 2021 

Our Reference: 

Dear HM Senior Coroner Alison Mutch OBE, 

Prevention of future death report following inquest into the death of Anthony Slack.  

Thank you for sending the Care Quality Commission (‘CQC’) a copy of the prevention of 
future death report dated 01 December 2020 following the sad death of Anthony Slack. 

We note the legal requirement upon the  CQC was to respond to your report within 56 
days,  by  the  26  January  2021  but  you  kindly  agreed  to  extend  this  deadline  to  the  5 
February 2021.  

The registered provider of The Vicarage Residential Care Home at the time of Mr Slack’s 
death was Clarkson House Residential Care Home Ltd (the ‘Provider’).  

The  Provider  location  (The  Vicarage  Residential  Care  Home)  registered  with  CQC  is 
located  at  109  Audenshaw Road, Audenshaw,  Manchester,  M34 5NL.  The  Provider is 
registered for the regulated activity: Accommodation for persons who require nursing or 
personal care. There is a condition on the registration for this location, namely that the 
Provider must not provide nursing care under accommodation for persons who  require 
nursing or personal care at The Vicarage Residential Care Home. 

The role of the CQC & Inspection methodology  

The role of the CQC as an independent regulator is to register health and adult social 
care  service  providers  in  England  and  to  inspect  whether  or  not  the  fundamental 
standards are being met.   

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 Our current regulatory approach involves inspectors considering five key questions.  They 
ask if services are Safe; Effective; Caring; Responsive; and Well Led.  Inspectors use a 
series of key lines of enquiry (KLOEs) and prompts to seek and corroborate evidence and 
reassurance of how providers perform against characteristics of ratings and how risks to 
people are identified, assessed and mitigated.  Sources of evidence for the KLOEs can 
be  found  on  our  website  along  with  our  KLOEs  and  characteristics  of  ratings. 
https://www.cqc.org.uk/guidance-providers/adult-social-care/key-lines-enquiry-adult-
social-care-services . 

The regulatory framework requires registered persons to meet fundamental standards of 
care, standards below which care must never fall.  We provide guidance to providers on 
how they can meet these standards (Regulations 4 to 20A of the Health and Social Care 
Act 
‘Regulations’). 
https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulations-service-
providers-managers . 

(Regulated  Activities)  Regulations 

2014) 

2008 

(the 

Regulatory History 

Clarkson  House  Residential  Care  Home  Ltd  were  registered  to  carry  on  a  regulated 
activity at The Vicarage Residential Care Home in January 2011.  

Our last comprehensive inspection was October 2019. The service was rated as Requires 
Improvement. There was one breach of Regulation 9 of the Health and Social Care Act 
2008  (Regulated  Activities) Regulations  2014,  Person-centred  Care.  The  Provider had 
not  ensured  care  was  designed  to  meet  service  users'  needs  when  providing  social 
activities.  

We  found  an  infection  prevention  and  control  audit  had  been  completed  by  infection 
prevention  and  control  at  Tameside  in  March  2019  and  the  home  was  found  to  be 
compliant in all areas and received an overall score of 94%. Staff had completed training 
in infection prevention and control and wore personal protective equipment (PPE), such 
as disposable aprons and gloves, when supporting people with personal care.  

A new assessment had been developed to be used when admitting new residents. This 
included information about the support people needed and how those needs were to be 
met. It included people’s personal, social and medical histories. This would help to ensure 
people were appropriately placed and the home could provide people with the support 
they needed. There was a system for monitoring falls. Records showed that appropriate 
treatment  and  support  were  sought  in  a  timely  manner.  Care  records  were  reviewed 
regularly and updated when people’s needs changed. 

This rating meant that under the inspection methodology we were using at the time, the 
service would be inspected by October 2021, but earlier if concerns were raised about 
the safety and welfare of people receiving the service. 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Statutory Notification in relation to the Death of Mr. Slack 

CQC  received  a  statutory  notification  ‘Death  of  a  person  using  the  service’  from  the 
Provider  on  18  April  2020.  This  identified  the  cause  of  Mr  Slack’s  death  as  due  to 
suspected Covid 19 and that he had passed away in hospital. There were no details about 
the specific circumstances of Mr. Slack’s death, therefore CQC had further discussions 
with the Provider who confirmed that Mr Slack had a fall and that following attendance by 
the ambulance service had been diagnosed with suspected Covid 19. The Provider had 
followed the advice of the ambulance service, and government advice at the time, and 
isolated  Mr  Slack  in  his  bedroom.  Mr  Slack  had  been  admitted  to  hospital  on  11  April 
2020  when  his  condition  deteriorated.  The  Provider  confirmed  to  CQC  during  this 
discussion that they had sufficient supplies of PPE and had access to and were following 
government guidance in relation to Covid 19.  

In July 2020 as a result of information CQC received, unrelated to Mr Slacks death, we 
undertook  a  focussed  inspection.  This  was  a  targeted  inspection.  The  inspection  was 
focused in one key question; Is the service safe?  Within the safe domain our inspection 
focused  on  the  specific  areas  of  concern;  about  infection  control,  staff  training  and 
supervision, manual handling, building maintenance and management and reporting of 
safeguarding incidents.   

During this inspection we found no breaches of Regulation.  

Risks to people who used the service and staff, relating to infection prevention and control 
and specifically Covid 19, had been assessed and appropriate action taken. The Provider 
was promoting good infection control and hygiene practices.  

PPE  was  used  appropriately,  and  staff  had  received  additional  training,  including 
handwashing and use of PPE. Staff confirmed they knew what PPE they should wear and 
that they could access stocks of PPE.  

During  this  inspection,  we  found  the  Provider  demonstrated  they  were  aware  of 
government guidance in relation to Covid 19 and had systems in place to ensure it was 
implemented  in  the  home.  The  Provider’s  infection  prevention  and  control  policy  and 
admissions policy were up to date.  

The  service did  not  receive  a  rating  for this inspection  as  we  did not  look at  all  KLOE 
within the safe domain.  

Prevention of Future Deaths Report 

Following receipt of the concerns raised by the Coroner at the conclusion of the inquest 
into the death of Mr. Slack which resulted in the prevention of future deaths report. CQC 
undertook an unannounced, focused inspection of The Vicarage Residential Care Home. 
This was undertaken to ensure that the circumstances of Mr. Slack’s death did not raise 
concerns about any ongoing risk to current service users 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 The inspection commenced on the 18 January 2021. The inspection team consisted of 
one  Inspector.  The  inspection  was  focused  in  one  key  question;  Is  the  service  safe? 
Within the safe domain, our inspection focused on the specific areas of concern raised in 
the report.  We looked at infection prevention and control (IPC). in accordance with the 
IPC thematic inspection methodology CQC developed as part of its response to the Covid 
19 pandemic. This provides a framework to assess the systems and processes providers 
have in place to respond to the Covid 19 pandemic. It includes reviewing infection control 
policies and procedures, staff and Provider knowledge and implementation of government 
guidance, access to and use of personal protective equipment (PPE), staff and resident 
testing and safe admissions to care homes.  

We also looked at risk management, falls management including post falls observations 
and protocols, accident and incident records, records of care provided and accessing and 
recording appropriate health support.  

The specific matters of concerns raised by the Coroner, in the report are addressed 
below: 

Matters of concern 

1.  The documentation available at inquest from the home was limited in 
detail. As a result, it was difficult to understand what observations had 
been undertaken by the care home staff who were monitoring him.  

2.  The  evidence  given  at  the  inquest  was  that  the  observations  were  of 
limited  quality  notwithstanding  the  diagnosis  of  Covid  19  and  his 
vulnerability.   

At our inspections in October 2019 and July 2020 we found care records, including 
risk  assessments  and  care  plans  were  person  centred  and  sufficiently  detailed  to 
guide staff in the support and care people needed. We also found that records of care 
and support provided were completed by staff. 

CQC expects all services to have robust systems to ensure the quality of service and 
monitors  that  policies  and  procedures  are  being  followed.  We  found  there  were  a 
variety  of  checks  and  audits  carried  out  in  the  home  to  ensure  it  was  safe  for  the 
people living there. These included reviews of action taken following accidents and 
incidents, care record entries and observation records. These were overseen by the 
Provider to ensure any actions were completed. 

At our inspection in January 2021, we found that improvements had been made to 
the  systems  and  processes  for  post  falls  management.  This  included  contacting 
Digital Health Team at set intervals post fall. This enabled Digital Health to support 
staff  with  observations;  these  were  then  recorded  on  the  person’s  medical  notes. 

4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Digital  Health  have  supplied  monitoring  equipment  including  blood  pressure  and 
pulse  rate  monitors  to  providers  to  enable  this.  A  detailed  protocol  had  been 
introduced  that  included  guidance  to  staff  on  specific  observations  that  should  be 
taken and when they should be taken.  

We saw that there was also an updated monitoring record for staff to complete when 
undertaking regular routine well-being checks. These required staff to indicate where 
the person was and what they were doing.  

Staff we spoke with during the inspection were able to detail all aspects of the new 
system and what observations they were expected to complete if someone was ill or 
if  they  were  undertaking  routine  well-being  checks.  The  Provider  had  arranged 
training with Tameside Metropolitan Borough Council (TMBC) to improve daily record 
keeping.  

3.  The inquest heard that after the home went into lockdown Covid 19 was 
found  in  residents  within  the  home.  At  the  inquest  the  home  were 
unclear  if  staff  had  brought  it  into  the  home  or  if  the  admission  of 
residents from the community who were not tested for Covid 19 before 
admission  were  the  cause  of  it  entering  the  home.  There  was  no  risk 
assessment in place relating to admission of new residents.  

Throughout  the  Covid  19  pandemic  government  guidance  has  been  issued  to 
providers on admissions to care homes and testing of staff. This did not at the time 
of Mr Slacks death include the requirement to test staff or residents before admission.  

We have confirmed, through engagement conversations with the Provider in March, 
April and May 2020, and at our inspections in July 2020 and January 2021 that the 
Provider  was  aware  of  and  was  adhering  to  government  guidance  on  the  safe 
admission of people to care homes. This included isolation of new or Covid positive 
residents.  

The  Provider  has  also  confirmed  they  are  now  undertaking  the  required  regular 
resident and staff Covid 19 tests.  

4.  Staff were unclear as to the PPE requirements as a result of the changes 
to  the  guidance  that  were  occurring  on  a  regular  basis  and  it  was 
unclear how changes were being shared with staff and implemented.  

We have confirmed, through engagement conversations with the Provider in March, 
April and May 2020, and at our inspections in July 2020 and January 2021 that the 
Provider was accessing the government guidance current at that time on use of PPE. 
On all of these occasions the Provider demonstrated that they were aware of current 
guidance and were ensuring staff were made aware of any changes via a staff Whats 
App group, emails and staff handovers. The Provider confirmed they were receiving 
updates from TMBC which included links to any changes in guidance to PPE use. 

5 

 
 
 
 
 
 
 
 
 
 
 
 
 They  confirmed  they  were  also  accessing  COVID-19  related  guidance  for  ASC 
providers on the CQC website.  

During our inspections of July 2020 and January 2021, we observed staff wearing 
appropriate PPE. Staff had received additional training, including handwashing and 
use  of  PPE.  Staff  confirmed  to  CQC  during  both  inspections,  that  they  received 
updates from the Provider to inform them of any changes in guidance and knew what 
PPE they should wear and that they could access stocks of PPE. 

testing  and 

5.  The inquest heard that the ambulance was delayed due to shortages of 
available ambulances. The inquest was told this was driven by a number 
of factors. This included staff absences due to the need to self-isolate 
awaiting 
to 
ambulances  required  by  Covid  19.  The  inquest was  told  that at some 
points in the day and in some acute trusts, ambulance crews were being 
supported  by  on  site  cleaning  crews.  This  meant  quicker  turnaround 
times and increased capacity. This was not consistent and not on a 24/7 
basis. As a result, ambulances were struggling to reach vulnerable and 
unwell members of the public and transport them to an acute setting. 

increased  cleaning  needs 

in  relation 

As stated in the Regulation 28 Report, there are several contributing factors resulting in 
North  West  Ambulance  Service  (NWAS)  delayed  response  times.  NWAS  have  been 
transparent and open with the CQC to ensure we are aware of their performance and the 
factors that impact it.  

We  are  continually  monitoring  the  regional  ambulance  picture,  through  ongoing 
engagement, performance reports and internal meetings.  

NWAS share with us their weekly HAS Report, Delayed admissions report and Weekly 
Snapshot (total turnaround for each Acute). We have monthly engagement meetings and 
attend national meetings.  

NWAS have informed us they have adopted the AACE guidance to ensure appropriate 
changes have been made to ensure safety of staff and patients. For example, designated 
cleaning  teams  with  appropriate  training  have  been  assigned  to  stations  and  hospital 
premises  to  support  ambulance  crews  decontaminate  vehicles.  NWAS  have  placed 
decontamination areas outside hospitals, so that ambulances who have conveyed Covid 
19 patients can be deep cleaned at the hospital site rather than go back to the stations. 
Vehicle cleaning is in line with PHE guidance, cleaning all contact areas after each patient 
is essential to ensuring both staff and patients are safe. Cleaning sites have been set up 
on hospital sites to make the deep clean process faster. This is so that ambulances can 
get back on the road quicker. This has reduced the risk of transmitting the virus but does 
impact on time.  

6 

 
 
 
 
 
 
 
 
 
 
 
 
 In addition, we have been made aware of the impact on response times due to the 
delays caused by hand over at hospitals.  

With regards to The Vicarage Residential Care Home, CQC expects registered persons 
to keep up to date with, take on board and implement government guidance. We have 
during the Covid 19 pandemic remained in regular contact with the Provider. This included 
engagement calls in March, April and May 2020. These were supportive calls to ensure 
that  the  Provider  was  aware  of  any  updates  to  guidance  and  to  signpost  appropriate 
support if needed. CQC also published COVID-19 related guidance for ASC providers on 
the CQC website.  From mid-March 2020 the Provider also received daily updates from 
TMBC which included updates on guidance, resources and support. 

CQC is satisfied that appropriate steps have been taken to  ensure that staff recognise 
risks from falls and illness and are aware what action they need to take, including ensuring 
appropriate medical support, what observations are expected, and how to document them 
appropriately. This is based on our previous knowledge of this location and how they have 
responded following the circumstances around Mr Slacks death. 

CQC  is  of  the  opinion  that  the  new  processes  that  the  service  have  adopted  have 
addressed  the  known  risks  in  this  care  home.  CQC  believe  the  actions  taken  by  the 
Provider are what could reasonably be expected of them.  

In order to ensure that this risk is minimised to the lowest possible level and to ensure 
service  users  are  not  placed  at  risk  at  The  Vicarage  Residential  Care  Home,  we  are 
continually  monitoring  the  service  and  liaising  with  the  Local  Authority  to  review  any 
ongoing risks and feedback.  

In  summary,  CQC  have  reviewed  systems  in  place  at  The  Vicarage  Residential  Care 
Home  and  we  are  assured  that  the  Provider  has  taken  action  to  improve  and  further 
reduce  risks  within  this  care  home.  This  will  be  reviewed  at  our  next  inspection  of  the 
service. 

Should you require any further information then please do not hesitate to get in touch.    

Yours sincerely, 

Interim Head of Inspection North West – Adult Social Care 

7

Greater Manchester Health and Social Care Partnership 
4th Floor 
3 Piccadilly Place 
London Road 
Manchester M1 3BN 

T: 

E: 

Date: 19 February 2021 

Ms A Mutch OBE 
HM Senior Coroner 
Coroner’s Court 
1 Mount Tabor Street 
Stockport 
SK1 3AG   

Dear Ms Mutch  

Re: Regulation 28 Report to Prevent Future Deaths – Anthony Slack 13.04.2020    

Thank you for your Regulation 28 Report dated 1 December 2020 concerning the 
death of Anthony Slack on 13 April 2020. Firstly, I would like to express my deep 
condolences to Anthony Slack’s family.  

The inquest concluded that Anthony Salck’s death was a result of 1a) Community 
acquired pneumonia; 1b) COVID 19; 2) Dementia, chronic obstructive pulmonary 
disease, asbestos related pulmonary fibrosis, pleural plaques, type 2 diabetes.  

Following the inquest you raised concerns in your Regulation 28 Report to Greater 
Manchester Health and Social Care Partnership regarding the quality of observations 
and availability of documentation from the care home, the lack of risk assessments 
for new admissions to the care home, a lack of clarity around PPE guidance for care 
home staff at the time and the availability of ambulances in the area. 

I have noted that your Regulation 28 letter has also been sent to The Vicarage 
Residential Care Home, Public Health England and NHS England. Whilst I may 
summarise some of the actions taken by these organisations, I will leave it to the 
named respondents to address the specific concerns relevant to them which you 
have expressed. My letter therefore addresses the issues that fall within the remit of 
GMHSCP. 

Summary of actions taken or being taken by the organisation involved. 

The Care Home confirmed that; 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1.  The Provider/Registered Manager is speaking to staff individually to reiterate 
the need for thorough record keeping in relation to falls but also generally. A 
documentation awareness training offer has been made to the 
Provider/Registered Manager by Tameside and Glossop CCG Quality 
Improvement Team. This has been accepted and sessions will take place in 
February via Microsoft Teams. The Local Authority require all providers to 
comply with good record keeping standards as required by their CQC 
registration. 

2.  There is a Digital Health service for care homes in the borough and the CCG 
Contacts Performance and Quality Improvement teams have spoken to the 
provider and re-emphasised the need to seek advice from the Digital Health 
team, both following a fall but also in the event that there is some visible 
deterioration in a resident.  

3.  At the time of Mr Slack’s death there was no way of ascertaining how Covid-

19 entered the home. Whilst the home had been ‘locked down’ they were still 
accepting patients from the acute trust who had to create beds for the 
increasing numbers of covid-19 in-patients they had. Furthermore at that time 
there was no routine testing of care home staff or residents. Staff are now 
PCR tested weekly and have twice weekly lateral flow tests and residents are 
PCR tested monthly and any symptomatic resident has access to lateral flow 
testing also. The majority of residents and several staff have now had the first 
vaccine. The Provider/Registered Manager confirmed that the visitor’s policy 
has been updated for professionals and relatives (ensuring testing). They 
have also updated the admission procedure with regards to covid-19 and risk 
assessment (require negative test on admission) 

4.  Local Population Health colleagues provide written guidance on infection 

prevention and PPE every time there is a policy change.  The CCG and ICFT 
now provide infection prevention webinars to support the care home sector 
and The Vicarage have positively engaged with these webinars, enabling 
several of their staff to access them. The local authority ensure no providers 
have been without PPE. The Provider/Registered Manager assured the CCG 
that there is clear guidance up in the home around PPE . Regular IPC audits 
are in place by IPC teams.  

5.  Throughout March 2020, operational teams at NWAS liaised with local 

Emergency Departments to establish cleaning teams to assist ambulance 
crews with the additional cleaning required following each handover. This 
partnered service meant that once a patient had left the ambulance, a cleaner 
would enter the saloon of the vehicle and clean the ambulance on the crews’ 
behalf whilst they completed handover, in order to improve ‘handover to clear’ 
time. The roll-out of this initiative was initially challenging due to the differing 
structural setups of local Emergency Departments, however as part of an 
initial roll out, the first Emergency Department went live 6 April 2020 with a 

 
 
 
 
 
 
 
 two shift system operating from 06:00-14:00 and 14:00-22:00 with two person 
per shift. The initiative was rolled out to seven other Emergency Departments 
in the North West. Following the initial roll out, a feasibility review was 
undertaken which highlighted periods of inactivity between 06:00-08:00 and 
19:00-22:00. As suce, the cleaning service has been revised and is now 
offered between 08:00-19:00 at each location. In response to the increasing 
pressure on the NWAS service, the cleaning service was extended further 
and NWAS crews are now supported by on-site cleaning crews at sixteen 
Emergency Departments across the North West. The cleaning service was 
not in place at Tameside Hospital at the time of Mr Slack’s attendance, though 
it has been confirmed that such a service is now provided there. Should an 
NWAS crew attend an Emergency Department at a time or location where the 
on-site cleaning crew is not in operation, ambulance crews are advised to 
complete onboard cleaning themselves, in the usual way. 

Actions taken or being taken to prevent reoccurrence across Greater 
Manchester. 

1.  Learning to be presented/shared with the Greater Manchester Quality Board.  

This meeting is attended by commissioners, including commissioners of 
specialist services, regulators, Healthwatch and NICE. 

2.  A Greater Manchester Infection Prevention and Control Care Home Cell has 
been established to interpret guidance and ensure a clear and consistent 
message to the care homes across Greater Manchester. 

3.  A monthly webinar has been organised, attended by over 100 care homes, to 

explain the science that supports the guidance, the interpretation of the 
guidance and to share best practice.  The 5th Webinar is to be broadcast on 
23rd February. This webinar and all the previous webinars are available to 
view on YouTube.  

4.  Tameside Local Authority, CCG and the care home have been invited to 

share the learning from this event at a quality improvement meeting on the 
15th March 2021.  The Quality Improvement Group meet monthly to share 
best practice and lessons learned. This group is attended by all 10 CCGs and 
LAs from across GM along with care home providers and key stakeholders 

The Greater Manchester Health and Social Care Partnership (GMHSCP) is 
committed to improving outcomes for the population of Greater Manchester. In 
conclusion key learning points and recommendations will be monitored to ensure 
they are embedded within practice. 

I hope this response provides the relevant assurances you require. Thank you for 
bringing these important patient safety issues to my attention and please do not 
hesitate to contact me should you need any further information. 

 
 
 
 
 
 
 
 
 
 
 
 Yours sincerely 

Chair of GM Medical Executive, GMHSCP

National Medical Director  
NHS England & NHS Improvement  
Skipton House 
80 London Road 
London 
SE1 6LH 

 2nd March 2021  

Ms Alison Mutch 
Senior Coroner 
Greater Manchester South 
Stockport Coroners Court 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

By email: 

 Dear Ms Mutch,  

Re: Regulation 28 Report to Prevent Future Deaths – Anthony Slack (DOD: 
13.04.2020) 

Thank  you  for  your  Regulation  28  Report  dated  1  December  2020  concerning  the 
death of Mr Anthony Slack on 13 April 2020. Firstly, I would like to express my deep 
condolences to Mr Slack’s family.  

The Regulation 28 report concluded that Mr Slack’s death was a result of recognised 
complications of COVID-19 exacerbated by an industrial disease. I note the medical 
cause of Mr Slack’s death was as follows: 

1a) Community Acquired Pneumonia 
1b) COVID-19  
2) Dementia, Chronic Obstructive Pulmonary Disease, Asbestos Related Pulmonary 
Fibrosis, Pleural Plaques, Type 2 Diabetes 

At  the  conclusion  of  the  inquest  you  raised  concerns  in  your  Regulation  28  Report 
addressed  to  NHS  England  regarding  the  delayed  ambulance  attendance  due  to 
shortages of available ambulances. I understand that the inquest heard evidence that 
this was as a consequence of COVID related absences amongst ambulance staff and 
further, the additional cleaning requirements. The inquest was told that at some points 
in the day and in some acute trusts, ambulance crews were being supported by on-
site  cleaning  crews,  which  resulted  in  quicker turnaround  times  and  thus  increased 
ambulance  capacity.  However,  the  witness  indicated  that  such  support  was 
inconsistent and not offered on a 24/7 basis.  

I have liaised directly with the North West Ambulance Service (NWAS) in respect of 
your concerns. 

NHS England and NHS Improvement 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The graph below shows the average ‘handover to clear’ times from April 2018 to March 
2020 i.e. the elapsed time between the point at which a patient is handed over into the 
care of the Emergency Department and  when an ambulance crew are able to clear 
from an incident to make themselves available for further emergencies. 
The  graph  demonstrates  that  hand  over  to  clear  times  had  consistently  remained 
within the 15-minute national target but did increase in March 2020, which has been 
attributed  to  the  additional  cleaning  required  as  a  consequence  of  COVID  –  19 
pandemic.  

Throughout  March  2020,  operational  teams  at  NWAS  liaised  with  local  Emergency 
Departments to establish cleaning teams to assist ambulance crews with the additional 
cleaning required following each handover. This partnered service meant that once a 
patient had left the ambulance, a cleaner would enter the saloon of the vehicle and 
clean the ambulance on the crews’ behalf whilst they completed handover, in order to 
improve ‘handover to clear’ time. The roll-out of this initiative was initially challenging 
due  to  the  differing  structural  setups  of  local  Emergency  Departments,  however  as 
part of an initial roll out, the first Emergency Department went live 6 April 2020 with a 
two shift system operating from 06:00–14:00 and 14:00–22:00 with two persons per 
shift. The initiative was rolled out to seven other Emergency Departments in the North 
West. 

Following  the  initial  roll  out,  a  feasibility  review  was  undertaken  which  highlighted 
periods of inactivity between 06:00-08:00 and 19:00 to 22:00. As such, the cleaning 
service has been revised and is now offered between 08:00–19:00 at each location. 

In response to the increasing pressure on the NWAS service, the cleaning service was 
extended further and NWAS crews are now supported by on-site cleaning crews at 
sixteen Emergency Departments across the North West. 

I understand that the cleaning service was not in place at Tameside Hospital at the 
time of Mr Slack’s attendance, though I can confirm that such a service is now provided 
there.  

 
 
 
 
 
 
 
 Should an NWAS crew attend an Emergency Department at a time or location where 
the on-site cleaning crew is not in operation, ambulance crews are advised to complete 
on-board cleaning themselves, in the usual way. It should be noted that even at the 
height  of  the  COVID-19  pandemic,  the  handover  to  clear  times  have  consistently 
remained well within the 15-minute national target. 

Thank you for bringing this important issue to my attention and please do not 
hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director

By email 
Alison Mutch, Senior Coroner 
c/o 

Our ref: 

Dear Alison Mutch, 

Public Accountability Unit 
Wellington House 
133-155 Waterloo Road 
London SE1 8UG 

  T  

www.gov.uk/phe  

26 January 2021 

Re: Inquest into the death of Anthony Slack 

Thank you for sending the attached report for Public Health England’s (PHE) 
consideration. 

Under the Coroners and Justice Act 2009, please find below PHE’s response in 
relation to the investigation of the death of Anthony Slack. 

Care homes have been particularly vulnerable to severe outbreaks of COVID-19 
during the pandemic, both in the UK and internationally. This reflects the fact that the 
virus spreads more readily in large residential settings than between households, 
and COVID-19 causes particularly severe disease with increasing age and in the 
presence of underlying conditions. Tragically, there have been very large numbers of 
deaths in care homes during the pandemic. PHE has been working very closely with 
key stakeholders throughout the pandemic to address a wide range of issues to help 
reduce the risk of COVID-19 entering care homes, to reduce the risk of transmission 
when there is an incursion of infection and to improve the health outcomes of those 
who become infected.  

PHE has established a national team to lead the organisational response to COVID-
19 in adult social care settings. This team is involved in a number of activities, 
including: 

•  Coordination of the PHE response to COVID-19 in adult social care settings, 
including holding a weekly meeting with Health Protection Teams (HPTs) and 
key partners from the Department of Health and Social Care (DHSC) to 
review intelligence, share learning and support policy and public health 
practice in relation to outbreaks and incidents in care homes  

•  National surveillance of COVID-19 incidents and outbreaks in care homes 
•  Regular liaison with DHSC, including a weekly meeting with the Minister for 

Social Care to take a deep dive into issues relating to care home outbreaks to 
inform policy making 

•  Membership of the Scientific Advisory Group for Emergencies (SAGE) Social 
Care Working Group to review emerging scientific evidence and inform policy 
development 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  Membership of the Social Care Sector COVID-19 Support Taskforce to learn 

from the first phase of the COVID-19 pandemic and inform advice and 
recommendations to government and the social care sector. The 
recommendations from this taskforce informed the development of the 
government’s Adult Social Care Winter Plan 2020-2021 
https://www.gov.uk/government/publications/adult-social-care-coronavirus-
covid-19-winter-plan-2020-to-2021/adult-social-care-our-covid-19-winter-plan-
2020-to-2021  

•  Supporting DHSC in the delivery of the Adult Social Care Action Plan and 

Adult Social Care Winter Plan 

Throughout the pandemic, PHE HPTs have been working with local partners, 
including directors of public health, local authorities and clinical commissioning 
groups to support individual care homes during the pandemic. This has included 
providing advice on infection prevention and control measures to prevent incursion of 
infection into care homes, and supporting care homes in response to outbreaks. 
Outbreak response has included conducting risk assessments, arranging outbreak 
testing and advising on additional infection prevention and control measures. 

PHE has supported DHSC and NHS England in the development of a number of 
guidance documents to support the adult social care sector in responding to the 
pandemic, including guidance on admission and care of residents, discharge of 
residents from hospital, infection prevention and control, personal protective 
equipment and visiting. 

PHE research teams have conducted a number of research projects, including 
epidemiological and genomic research, to help understand key issues in relation to 
the entry and spread of COVID-19 in care homes to inform the public health 
response. 

PHE collates a weekly digest of research evidence in relation to the prevention and 
control of COVID-19 in home care/care home settings to inform the public health 
response. 

PHE has been heavily involved in the development of the COVID-19 vaccination 
programme and the prioritisation of vaccination for care home residents and staff. 

In respect of personal protective equipment (PPE) where the Regulation 28 Report 
states: 

"Staff were unclear as to the PPE requirements as a result of changes to 
the guidance that were occurring on a regular basis and it was unclear 
how changes were being shared with staff and implemented" 

In this matter, the national guidance on use of PPE developed rapidly during March 
and April, as the pandemic was declared and actions taken to respond to it. In those 
first few weeks, knowledge and understanding across the Health and Care System 
changed very quickly. In addition, availability of PPE was limited. Changes to 
guidance on use of PPE reflected the entire system adapting and responding to this 
complex situation. 

2 

 
 
 
 
 
 
 
 
 Communication of changes to all national guidance, including the use of PPE, was 
(and continues to be) delivered under the established PHE incident response 
governance structures, which were activated in March at the outset of the pandemic . 
Regarding PPE guidance during March and April, partners in Health and Social care 
across the North West of England received written communication in a timely and 
proportionate manner via the PHE NW Incident Control Centre (ICC) email cascade 
on all updates and changes to guidance. This included all NW Directors of Public 
Health, Directors of Adult Social Care, with an onward cascade via Local Authority 
routes to Care Homes for which they had responsibility. In addition, PHE NW's ICC 
communicated directly with local Infection Prevention and Control Teams and North 
West Association of Directors of Social care (ADASS) to minimise the risk that 
guidance was missed. 

Guidance on the use of PPE has continued to develop in line with increasing 
scientific knowledge. PHE has worked with stakeholders in the adult social care 
sector to ensure that developing guidance meets the needs of the sector. As an 
example, PHE has developed video tutorials on the donning and doffing of PPE, and 
an illustrated guide to PPE for community and social care settings.  

Remaining concerns 

It is not appropriate that this response provides detail regarding points in the 
Regulation 28 Report on the limited details in documentation available at the inquest 
from the home, the quality of observations and assessment of vulnerability of Mr 
Slack, the route of transmission of COVID-19 into the home and the delay of the 
ambulance, as these are outside the remit, control and responsibility of PHE.  

PHE understands that the Regulation 28 Report has been sent to the Care Quality 
Commission, The Vicarage Residential Care Home, NHS England, Greater 
Manchester Health and social care partnership who will be able to comment on the 
remaining concerns. Additionally, PHE has shared this report with the DHSC who will 
provide further comment. 

Please do not hesitate to contact PHE should we be of any further assistance in this 
matter.  

Yours sincerely, 
FOI Team 

3

Clarkson House Care Home Ltd / The Vicarage Care Home 

Action Plan 

Provider:  

Clarkson House Care Home Ltd/ The Vicarage Care Home 

This is following a  Reg 28 issued by the coroners following an inquest 

Care Home Manager  

Date plan started;  

Completed by:  

 18/10/2020    Based  on  information  gathered  at  the  inquest  and  updated  after  information  as  per  Reg  28 
letter received in December 2020. 

RED 
AMBER 

GREEN  

Still outstanding 
Some  work  completed  but  not  fully 
complete 
Work completed   
Task not identified   

 
 
                                  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Matters of Concern 

Plan of Action  

Review  Review  Review 

Comments/Timeline  

The  documentation  available  at  the  inquest 
from  the  home  was  limited  in  detail.  As  a 
result,  it  was  difficult  to  understand  what 
observations  had  been  undertaken  by  care 
home staff who were monitoring him. 

Documentation  training  in  house  has 
been completed. This has  been carried 
out by senior staff on a 1:1 basis with all 
staff. 
The  quality 
started 
documentation for all staff. 

Improvement  Team  has 
on 

training 

Teams 

The documentation and recording policy 
has  been  updated  and  reissued  to  all 
staff  both  hard  copy  and  via  group 
email. 

have 

reissued 

We 
relevant 
documentation  pro  formas  and  sourced 
out 
relevant  and  more  uptodate 
document  proformas  from  The  Quality 
Improvement Team  to be completed by 
staff  following  a  fall,  resident  being 
unwell,  loss  of  appetite  ,  loss  of  weight 
and  ensured  staff  are  conversant  with 
them and how to complete them through 
1:1  where  relevant  and  small  group 
sessions at handovers. 
We have included documentation as 
above as a high priority in our induction 
document for new staff. 

The evidence given at the inquest was that 
the  observations  were  of  limited  quality 
notwithstanding  the  diagnosis  of  Covid-19 
and his vulnerability. 

In April 2020 the situations that we were 
presented with were new and 
unexpected: 
Since then we have learnt a lot about 
Covid-19. Drawing from regular 
guidance provided by the local authority, 
public health England, CQC we keep 
our staff updated with new and updated 
changing advice through memos, 

18/10/20 

27/12/20 

22/01/21  All staff completed  

- 

Further  training  completed  today 
22/01/21 and other sessions booked 
for 29/01/21 and 05/02/21 

Continue to monitor 

Monitoring continues 

No  Further  Action  Required  at  the  moment 
/continue to monitor 

Continue to monitor  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 18/10/20 

27/12/20 

22/01/21 

Continue to monitor 

Awaiting to complete registration 
To monitor  

emails, whatsapp messages and group 
discussions at handovers. Our senior 
staff also carry out observations of our 
staff practice and adherence to 
instructions as per updated guidance. 

All our staff on site except for a few new 
starters have undertaken a specific 
Covid-19 course provided online by 
social care T.V and have all undergone 
infection control training provided by the 
Local Authority on a weekly basis. 
(previously twice weekly) .  We ensure 
that staff have  
refreshers as new information and 
guidance are regularly added onto the 
course. 

We have sourced out a new course  
specific to infection control and 
management leading to a level 2 
qualification. This is due to start by the 
15/2/2021 and the objective is for all 
staff to complete by the end of March 
2021. 
Details-Unit 1: principles of the causes 
and spread of infection in health care 
settings 
Unit 2: Principles of the importance of 
personal hygiene and health in the 
prevention and control of infection in 
health care settings  
Unit 3: Principles of decontamination, 
cleaning and waste management in 
health care settings. 
Unit 4: Principles of infection prevention 
and control in a health care setting. 

 
 
 
 
 
 
 
 
 
 
 
 found 

the  home  or 

lockdown  Covid  19  was 

The inquest heard that after the home went 
into 
in 
residents  within  the  home.  At  the  inquest 
the home were unclear if staff had brought it 
the  admission  of 
if 
into 
residents from the community who were not 
tested  for  Covid  19  before  admission  were 
the  cause  of  it  entering  the  home.  There 
was no risk assessment in place relating to 
admission of new residents. 

We have increased cleaning staff duty 
hours over the past 6 months to cater for 
more regular cleaning and disinfection in 
addition to new products being used for 
desanitisation. 
We have reviewed our admission policy 
and we are keeping it under regular 
review adding to it based on new 
guidance being provided by the local 
authority, PHE and our local infection 
prevention team based at Tameside 
General hospital 

Included in the above is PCR testing 
and lateral flow testing as guided by the 
Local Authority and government 
guidance. 
We undertake regular testing of 
residents and staff and keep the safe 
steps Covid app updated and this is  
monitored by the NHS regularly. 

We as Managers follow and attend 
meetings organized by the Local 
Authority (manager’s forums) and 
Greater Manchester infection control 
meetings and cascade down any new 
information we come across. 
We have undergone vaccinations (1st 
Dose) of most of our residents and staff 
in December 2020 and now await the 
second dose and a few requiring the 1st 
dose. 

Infection control audit to be planned as 
the next due audit was the end of 2020 
but due to the demands on the infection 
prevention team who normally carry out 

18/10/20 

27/12/20 

22/01/21  Continue to monitor 

Continue to monitor 

Continue to monitor 

Continue to attend 

Continue to monitor 

Date  of  audit  to  be  confirmed  by  the 
quality improvement team by the end of 
January 2021 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 to 

the  PPE 
Staff  were  unclear  as 
requirements  as  a  result  of  changes  to  the 
guidance  that  were  occurring  on  a  regular 
basis and it was unclear how changes were 
being shared with staff and implemented 

Continue to monitor 

18/10/20 

27/12/20 

22/01/21 

Continue to monitor  

the audit this was not done. We have 
now arranged for the Quality 
improvement team to undertake and 
support us with an infection control and 
management audit in the coming weeks. 
In March/April 20 the guidance of the 
requirement and use of PPE was 
limited. We are implementing the use of 
correct PPE as guided by the local 
authority and infection control team. Any 
changes or new advice provided by the 
local authority and other relevant 
authorities are specifically cascaded 
down to the staff electronically and 
through memos and handovers. We can 
confirm  we have stock of PPE’s that 
could last us for 4-6 weeks at the very 
least. 

We acknowledge that at the beginning 
of the pandemic of March/April 2020 
there was a lack of clarity as to PPE 
requirements and there were regular 
changes in the guidance on a regular 
basis. Initially the changes were 
communicated to staff at handovers but 
soon after all updates on changes in 
PPE requirements have  
been shared at handovers and group 
email and whatsapp group and this 
remains relevant to date. Please note 
that the use of appropriate PPE's and 
other precautions required forms a large 
part of the infection control and 
management training offered by the 
local authority.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The  inquest  heard  that  the  ambulance  was 
delayed  due 
to  shortages  of  available 
ambulances. The inquest  was told this  was 
driven by a number of factors. This included 
staff  absences  due  to  the  need  of  self-
isolate  awaiting  testing  and  the  increased 
cleaning  needs  in  relation  to  ambulances 
required by Covid 19. The inquest was told 
that at some points in the day and in some 
acute  trusts,  ambulance  crews  were  being 
supported  by  on-site  cleaning  crews.  This 
meant  quicker 
times  and 
increased capacity. This was not consistent 
and  not  on  a  24/7  basis.  As  a  result, 
reach 
ambulances  were  struggling 
vulnerable  and  unwell  members  of  the 
public  and  transport  them  to  an  acute 
setting. 

turnaround 

to 

Continue to monitor  

18/10/20 

27/12/20 

22/01/21 

Continue to monitor  

We acknowledge that the delays from 
the emergency services in periods of 
high need could impact on vulnerable 
and  unwell residents. We have updated 
our protocol as regards waiting times 
whereby in the event of an emergency 
e.g. fall or a resident becoming  very 
unwell, then staff to be proactive and 
keep updating 111 or 999 on at least an 
hourly basis. 

In addition we have reviewed our 
dispositions in terms  of  wifi capacity to 
enable us to seek advice and support 
digitally via skype or business whatsapp 
accessible from every corner of the 
building and every room of the building.  
The system is tested daily via an app by 
the manager.