Philip Taylor

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

Via email: c

Our Reference: 

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Telephone: 
Fax: 03000 616171 

4 February 2021 

Dear HM Senior Coroner Alison Mutch OBE 

Prevention of future death report following inquest into the death of Philip Taylor 

Thank you for sending us a copy of the prevention of future death report issued following 
the  sad  death  of  Philip  Taylor.  Our  condolences  are  with  the  family  and  friends  of  Mr 
Taylor.  

We  note  the  legal  requirement  upon  the  Care  Quality  Commission  to  respond  to  your 
report within 56 days, by 11 February 2021. 

Mr Taylor was  resident  at  Bamford  Close, a  location  registered  with  CQC at  Adswood 
Lane West,  Cale  Green, Stockport,  SK3  8HT.  The  Registered  Provider  in  operation of 
Bamford Close at the time of Mr Taylor’s death was Borough Care Ltd. The Provider is 
registered for the regulated activity Accommodation for persons who require nursing or 
personal care. The registered manager at the time was Selina Taylor.  

The role of the CQC & Inspection methodology  

The role of the Care Quality Commission (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.   

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 

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 and reassurance of how the provider performs 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. 

The  regulatory  framework  includes  providers  being  required  to  meet  fundamental 
standards  of  care,  standards  below  which  care  must  never  fall.    These  standards  are 
contained in Regulations 4 to 20A of the Health and Social Care Act 2008 (Regulated 
Activities) Regulations 2014 (“the 2014 Regulations”).  

Background 

On 18 June 2020, 
 from South Manchester Coroners’ Court contacted CQC 
to advise us of the unexpected death of Mr Philip Taylor at Stepping Hill Hospital on 6 
January 2020 and inform us that this matter was being investigated.  Due to a technical 
issue the provider had completed a statutory notification, but this had not been submitted 
and received by CQC. Following the information received on the 18 June 2020 a copy 
was immediately provided to the CQC inspector and this was submitted on 7 July 2020 
by  the  registered  manager  at  Bamford  Close.  The  statutory  notification  stated  that  Mr 
Taylor began to show signs of declining health on the 2 January 2020 and a visit from the 
doctor  was  undertaken  that  day  where  advice  was  to  encourage  food  and  fluids.  Mr 
Taylor’s health continued to decline the following day and the home contacted the doctor 
for  further  advice  and  subsequently  called  an  ambulance.  Mr  Taylor  was  admitted  to 
Stepping Hill Hospital on the 3 January 2020 and sadly passed away three days later on 
the 6 January 2020. 

Further discussion was undertaken with the registered manager and CQC was assured 
that  the  provider  and  registered  manager  had  taken  appropriate  action  to  support  Mr 
Taylor as his health declined and seek medical advice as required.  

Regulatory History 

Borough Care Ltd were registered to carry on a regulated activity at Bamford Close on 
18  January  2011.  Mr  Taylor  was  admitted  to  the  care home  on  4  April 2019.  The  last 
comprehensive inspection of the service was undertaken shortly after this in June 2019. 
The service was rated as good with no breaches of regulations being identified. Bamford 
Close  is a  residential care  home and  is registered  to  accommodate  a  maximum of  40 
people.  Bamford  Close  is  registered  for  the  regulated  activity  of  ‘Accommodation  for 
person who require nursing or personal care’ and a condition of their registration is that 
the register provider does not provide nursing care at this location.  

At the time of Mr Taylor’s death there were 38 people living at Bamford Close and staffing 
levels  were  in  line  with  the  service  dependency  assessment.  Staffing  included  care 
assistants, senior care assistants, the deputy manager and registered manager together 
with auxiliary staff including domestic and kitchen staff. 

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 Bamford  Close  is not a  location that  offers nursing  services  and so  retains  no  nursing 
staff.  

Matters of concern for CQC 

The staff in the care home were not medically qualified. The inquest heard that their ability 
to recognise and respond to an escalating risk of dehydration was limited. There was no 
national guidance to assist care home staff in understanding how to recognise; respond 
and escalate the risk of dehydration. 

In  accordance  with  CQC’s  regulatory  remit,  as  with  other  regulators,  we  highlight 
breaches of the regulations to a Provider and where appropriate ask them what they are 
going to do to make improvements. We do not tell them what they should do. That is for 
the  Provider  and/or  Registered  Manager  (both  being  Registered  Persons  for  CQC 
purposes) to decide.  

Registered Persons have a duty under Regulation 14 of the 2014 Regulations to ensure 
adequate nutrition and hydration for service users. The specific wording under Regulation 
14(4)(a) refers to “receipt by a service user of suitable and nutritious food and hydration 
which is adequate to sustain life and good health”. 

CQC does not publish detailed standards and expectations about specific conditions. To 
do so would duplicate the work of more appropriate expert sources (for example NICE 
and SCIE - see below). We expect Registered Persons to keep up to date with, take on 
board  and  implement  good  practice  standards  provided  by  relevant  authoritative 
organisations.  

Information  on  the  CQC  website  to  signpost  providers  on  meeting  Regulation  14  is 
available. This includes links to a variety of best practice guidance including Diet, nutrition 
and obesity (National Institute for Health and Care Excellence) which is deemed relevant 
to all service providers. Other specific guidance to adult social care service included links 
to BAPEN (British Association for Parenteral & Enteral Nutrition):  BAPEN: Malnutrition 
universal  screening  tool;    Malnutrition  Universal  Screening  Tool  (MUST)  explanatory 
booklet; Nutrition for specific groups (Royal College of Nursing); Nutrition support in adults 
(National  Institute  for  Health  and  Care  Excellence);  Nutrition  support  in  adults  (NICE); 
Nutritional care and older people (Social Care Institute for Excellence, March 2009). 

CQC also includes information on hydration in the Frequently Asked Questions section 
of  its  website.  This  section  provides  a  general  overview  of  some  of  the  issues  around 
hydration  that  Providers  may  need  to  consider  when  formulating  and  reviewing  their 
policies  and  practices.  In  conjunction  with  the  links  to  external  sources  provided  (see 
above), CQC expects Providers to be able to find the information they require to support 
the hydration needs of their Service Users. 

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 Other sources of guidance available in the public domain include: Getting it right every 
time (fundamentals of nursing care at the end of life) (Royal College of Nursing, 2015); 
SCIE  guidance  Nutrition  for  older  people  in  care  homes:  Dignity  in  care  videos; 
Dehydration in the elderly - British Nutrition Foundation; and Hydration and older people 
in  the  UK:  Addressing  the  problem,  understanding  the  solution  (International  longevity 
Centre UK, 2014). These provide examples of how to meet the nutritional and hydration 
needs of older adults. It should also be noted that research indicates that the signs and 
symptoms commonly used to detect dehydration are often ineffective in doing so in care 
home  residents and  that  nursing  and  care  staff focus  should  instead be  on  supporting 
older people to drink well (Effective hydration care in older people living in care homes; 
Nursing Times, 2019). 

Like  many  care  homes,  Bamford  Close  supports  care  staff  to  complete  the  Care 
Certificate. There are 15 standards to the Care Certificate and standard 8 relates to fluid 
and nutrition. This standard covers the  importance of good nutrition and hydration; the 
signs  and  symptoms  of  poor  nutrition  and  hydration  and  how  to  promote  adequate 
nutrition and hydration. Training records indicate that the majority of staff completed the 
care certificate or had other relevant qualification where this was pertinent to their role.  

One of the KLOEs for answering ‘Is this service Effective’ asks: How are people supported 
to eat and drink enough to maintain a balanced diet? Inspectors explore the arrangements 
in place to manage people’s nutritional and hydration needs, how people are involved in 
what they eat and drink and how risks to people with complex needs are managed. All 
KLOEs were reviewed following CQC’s inspection methodology during the inspection of 
the service in June 2019 (report published 18 July 2019), at which Bamford Close was 
rated Good.  

The death of Mr Taylor was reviewed as part of our regulatory duties, to assess whether 
there was any evidence of failings by a Registered Person that amounted to a breach of 
the  Regulations.  The  conclusion  of  the  initial  review  found  that  there  was  insufficient 
evidence of a breach of the Regulations. Mr Taylor had a nutrition and hydration care plan 
in place, along with a variety of other appropriate and relevant care plans. These were 
being reviewed on a monthly basis. An assessment of  Mr Taylor’s nutrition needs had 
also been recently reviewed in December 2019. Daily records were being completed and 
included food and fluid charts. The latter records both fluid offered and fluid taken by Mr 
Taylor, which would have assisted with auditing to ensure appropriate fluid levels were 
maintained. The meal chart is a similar mechanism for ensuring appropriate food intake.  

The fluid charts indicate that overall support to maintain adequate fluids levels was good 
but there had a reduced intake at times, possibly due to declining health and Mr Taylor’s 
diagnosed  chest  infection.  This  is  particularly  notable  on  3  January  2020,  the  day  Mr 
Taylor was admitted to hospital.  

In order to ensure that that this risk is minimised to the lowest possible level and to ensure 
service users are not placed at risk at Bamford Close, we are continually monitoring the 
service and liaising with the local authority to review any ongoing risks and feedback. 

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 In  summary,  the  requirement  is  placed on  Registered  Persons  to ensure  that they  are 
delivering care in a safe and effective way and doing all that is practicable to mitigate any 
risks.  CQC  will  continue  to  review  through  its  inspection  processes  the  systems  and 
processes  being  operated  by  those  services  it  regulates  and  will  challenge  and,  if 
appropriate, take enforcement action against a Registered Person where it finds that care 
is being provided in an unsafe way.  

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

Yours sincerely, 

Interim Head of Inspection North West – Adult Social Care 
Care Quality Commission 

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Our Ref: 

Ms Alison Mutch  
HM Senior Coroner, Greater Manchester South  
HM Coroner’s Court  
1 Mount Tabor Street  
Stockport SK1 3AG  

Dear Ms Mutch, 

From Helen Whately MP 
Minister of State for Care 

39 Victoria Street 
London 
SW1H 0EU 

15 March 2021 

Thank you for your letter of 17 December 2020 about the death of Philip Taylor.  I am replying as 
Minister with policy responsibility for adult social care.   

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Taylor’s death 
and the lengthy delay Mr Taylor experienced at the Emergency Department at the Stepping Hill 
Hospital, part of the Stockport NHS Foundation Trust. If you have the opportunity, please convey 
my condolences to Mr Taylor’s family.  Your report describes care that falls short of the high 
standards we expect from the NHS, and that the NHS strives to deliver, and it is important that we 
take the learnings from Mr Taylor’s death to improve the quality and safety of care.    

I am informed that the Stockport NHS Foundation Trust has provided you with information about its 
use of NEWS2, the National Early Warning Score for adults, and actions it has taken to strengthen 
oversight of patient acuity in the Emergency Department and processes for the escalation of care, 
among others.  I understand the Trust has reduced its nursing vacancies and there is senior level 
oversight of nursing rosters.    

I am aware that this is not the first Prevention of Future Deaths report you have issued concerning 
the pressures experienced by the emergency department at Stepping Hill Hospital, Stockport 
during the winter period of 2019/20.  It is right that the Trust, and its health system partners, reflect 
carefully on the concerns you have raised and take the necessary action to improve the safety and 
quality of urgent and emergency services in Stockport.   

As you will know from the Department’s responses to previous PFD reports raising these concerns, 
regulatory action was taken by the Care Quality Commission (CQC) after it identified similar 
concerns during an inspection at Stepping Hill Hospital in early 2020.    

The CQC found that people were not always kept safe and were at high risk of avoidable harm 
during periods of heavy demand on urgent and emergency care services.  Emergency care was 
consistently unable to be provided in a timely way; and there were significant issues with the flow 
of patients through the emergency department and the Hospital.  The report of the CQC’s 
inspection is available on its website1.    

Following the CQC’s inspection, health system partners in Stockport formed a system 
improvement board, that has representation from the CQC and NHS England and NHS 
Improvement (NHSEI), to oversee the implementation of an improvement plan.    

 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
  
  
  
  
  
  
  
  
  
 I am assured that progress is being closely monitored by the Trust Board and the 
CQC.  Furthermore, I am informed that the issues at Stockport NHS Foundation Trust have been 
escalated within NHSEI national governance structures, including to the Executive Quality Group 
(EQG), chaired by
, Chief Nursing Officer, 
, National Medical Director, and 
and the Joint Strategic Oversight Group with senior representation from the CQC, where progress 
is regularly monitored.  I have asked my officials to bring your report to the attention of NHSEI.    

Turning to the specific matters of concern in your report, you ask the Department to address two 
issues, the first, in relation to the Pathfinder clinical assessment tool; and the second about the 
availability of national guidance on recognising and responding to the risk of dehydration.   

In preparing this response, my officials have taken advice from health system leader, NHSEI; the 
independent regulator for care quality, the CQC; and the National Institute for Health and Care 
Excellence (NICE).   

I am advised by the North West Ambulance Service (NWAS) that Pathfinder is a clinical 
presentation-based, triage tool based on the Manchester Triage System, which is used worldwide 
by emergency clinicians and by a number of ambulance services in the UK.  It may be helpful to 
clarify that Pathfinder is not mandated for use nationally and it remains a decision for individual 
ambulance services as to which clinical triage tools they use.    

I understand that Pathfinder was developed by the Manchester Triage Group, with involvement 
from NWAS, as a tool to support ambulance clinicians prior to them undergoing training on the full 
Manchester Triage System. The Pathfinder tool contains the main general discriminators of the 
Manchester Triage System, as well as some specific discriminators, however, whereas the full 
Manchester Triage System has 53 presentational charts, Pathfinder has just two; Medical and 
Trauma.   

I am informed by NWAS that a review of the ambulance response to Mr Taylor identified the point 
on Pathfinder that the paramedic at the scene would have reached based on Mr Taylor’s clinical 
presentation, specifically, a NEWS2 score of above five and a reduced level of 
consciousness.  Both these clinical factors elicit the ‘red priority response’, ‘Stabilise and 
immediate transportation to ED’.  NWAS advises that it was therefore clear from Pathfinder that an 
immediate transfer to hospital was required.  I am further advised that NWAS investigation of the 
ambulance response to Mr Taylor identified other factors that impacted on the length of time taken 
to transfer Mr Taylor to hospital, including the need to stabilise and obtain the contextual history.     

I am assured by the NWAS that having considered the concerns you have raised carefully, it 
believes that changes are not required as a result of this incident and that Pathfinder remains a 
safe and effective assessment triage tool.   

You may wish to note that during the review of this incident, those responsible for the Pathfinder 
tool identified two improvements (not directly related to this incident) that will be put forward for 
action.  These are an amendment to the Pathfinder chart to include guidance on timeframe for 
transfer to all red priority boxes; and to include ‘possible sepsis’ as a red priority outcome to ensure 
that where a patient’s clinical presentation is triggering on a sepsis screening tool, that it is also 
captured in Pathfinder as a failsafe where patient observations fall outside the NEWS2 
parameters.   

In relation to the national guidance that is available to care home staff on recognising and 
responding to the risk of dehydration, I am advised that in its response to you, the CQC has 
provided a detailed explanation of the guidance and best practice materials that are available.  I 
will not repeat the detail here.  However, you may wish to note that Departmental officials have 
made enquiries with NICE, which has confirmed that appropriate guidance is available, issued by 
NICE itself and others.    

  
  
  
  
  
  
  
  
  
 For example, National Guideline 148: Acute Kidney Injury acknowledges that there can be practical 
difficulties in patients with dementia (recommendation 1.1.12) which may make becoming 
dehydrated more likely.  In addition, NICE guideline, Older people with social care needs (NG223), 
identifies the need to maintain hydration for such patients and includes specific recommendations 
relating to hydration with regard to care in care homes (recommendation 1.5.13) and training for 
health and social care practitioners (recommendation 1.7.2).  I understand guidance has also been 
issued by the Social Care Institute for Excellence (SCIE); British Nutrition Foundation and others.   

The Care Certificate4, that has 15 standards that define the knowledge, skills and behaviours 
expected of roles in the health and social care sectors, includes a standard (Standard 8) relating to 
fluid and nutrition.    

Registered providers have a duty to deliver care safely and effectively.  In particular, to ensure 
adequate nutrition and hydration for their service users; and that they employ suitably qualified, 
competent and experienced staff, that are supported with the right training, professional 
development and supervision necessary for them to carry out their role and 
responsibilities.  Registered providers are expected to adhere to and implement national guidance 
and standards to ensure high standards of care.  As well as signposting the guidance available, the 
CQC website provides information on issues around hydration that registered providers may need 
to consider when formulating and reviewing their local policies.    

I am aware that the CQC has advised in its response to you that it identified no breach of the 
Regulations when it reviewed the death of Mr Taylor.  Mr Taylor had a nutrition and hydration care 
plan in place; an assessment of Mr Taylor’s nutrition needs had recently been made; and daily 
food and fluid records were being completed.  Training records at the Home indicated that the 
majority of staff had completed the Care Certificate or had other relevant qualifications pertinent to 
their role.  In line with its regulatory responsibilities, the CQC will continue to monitor the Home.   

I hope this response is helpful.  Thank you for bringing these concerns to my attention.   

HELEN WHATELY

4th Floor 
Stopford House 
Piccadilly 
Stockport 
SK1  3XE 

Tel: 

www.stockportccg.nhs.uk 

Our ref:  

28 January 2021 

Strictly Private & Confidential 
Ms Alison Mutch 
H M Senior Coroner 
1 Mottram Street 
Mount Tabor  
Stockport 
SK1 3PA 

Dear Ms Mutch 

Regulation 28 Report -  Mr Philip Jess TAYLOR   

I refer to your letter dated 17 December 2021 in relation to the above and I am sorry 
to  learn  of  circumstances  surrounding  the  death  of  Mr  Taylor  and  offer  my  sincere 
condolences to his family. 

Whilst  the  Regulation  28  Report  requests  information  from  a  number  of  different 
organisations, this response aims to address the issues highlighted as specific to NHS 
Stockport Clinical Commissioning Group (CCG). 

You have raised two points which I will address in order:- 

  GP did not carry a thermometer when attending Mr Taylor at the  care 

home 

Following a review of the events surrounding this particular case, Dr 
 explained 
that  when  visiting  the  Care  Home  to  attend  Mr  Taylor  he  did  carry  equipment  with 
him, including a thermometer and pulse oximeter.  However he had left his main bag 
in the car when he entered the home.  On reflection he acknowledges that he should 
have  ensured  that  he  did  have  access  to  this  equipment  in  case  of  need  and  he 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 confirms  that  it  is  now  his  practice  to  carry  this  equipment  with  him  whenever  he 
attends a patient away from the practice.   

  Delay in updating the clinical records following the visit 

In  circumstances  where  a  patient  is  attended  after  the  end  of  the  surgery  working 
day  it  was  Dr 
  practice  to  update  the  clinical  record  on  his  return  to  the 
practice,  which  on  occasion  could  be  the  following  morning  as  care  home  visits  can 
often  take  place  at  the  end  of  the  working  day.    Stockport  GPs  do  have  access  to 
mobile  technology  enabling  immediate  update  of  the  clinical  system  at  the  time  of 
the  consultation.    Dr 
  has  confirmed  that  he  will  now  carry  the  mobile 
technology  with  him  and  will  update  patient  records  immediately  following 
consultation / visit.  

I  am  mindful  that  steps  taken  now  cannot  undo  what  happened  in  this  case,  and  I 
am satisfied that from a clinical perspective, the failure to carry equipment / update 
records did not impact on the outcome for this gentleman.  However my expectation 
is that all Stockport GPs do carry basic equipment to enable the recording of clinical 
observations  and  for  patient  records  to  be  updated  at  the  point  of  consultation, 
wherever possible.  I am sorry that this did not happen in this case and I will ensure 
 adheres to this standard of 
that appropriate checks are made to ensure that Dr 
practice. 

Yours sincerely 

Dr 
Medical Director