Elizabeth Pamment

Coroner ME Hassell

Senior Coroner

Inner North London

St Pancras Coroner’s Court
Camley Street

London

Nic 4PP

By Email Only

Dear Madam

EP INQUEST - REGULATION 28 REPORT RESPONSE

Thank you for your letter of 8 January 2021. We are grateful to you for bringing your concerns to our
attention following the inquest hearing of Mrs Elizabeth Pamment at which Peabody were an
interested Person. ZEEE the Older People’s Housing and Support Manager and
HE Scheme Manager attended the inquest to provide evidence on behalf of Peabody.

Background to Peabody’s service at Alleyn House

Alleyn House is a sheltered housing scheme in Islington which is part of Peabody's Whitecross Street
Estate and is home to 31 residents. Peabody own and manage 34 sheltered housing schemes in
London. These provide 992 units of accommodation for tenants who are over 55.

The sheltered housing scheme provides for independent living. Each tenant has a self-contained flat
with their own front door and they are free to come and go as they please. Peabody provides a
‘Scheme Manager’ who is there during office hours to respond to emergencies, deal with resident
queries, to prevent social isolation by organising events and activities and to provide an enhanced
housing management service by assisting with organising repairs and general building management.

Peabody does not provide care, but housing related support via the Scheme Manager (who is on site
35 hours a week — 9am to Spm Monday to Friday). The people residing at the service (the residents)
are generally independent and have full capacity. For the avoidance of any doubt, there is no care
support service on site unless tenants make their own arrangements directly with a care provider. As
Peabody do not provide care or any healthcare regulated activities at Alleyn House, this sheltered
housing scheme is not a CQC regulated service.

We supply telecare to residents in the form of a ‘Careline’. This provides the opportunity for residents
to call for help in an emergency. The service can be accessed through alarm/response call points and
intercoms which are positioned throughout the accommodation in both residents’ flats and in
communal areas. The system can also be accessed through wearable devices such as watches and
pendants where requested by residents. If an alarm is triggered, it goes to the staff on site during
office hours and to the out of hours Careline provider out of hours. This out of hours Careline service
is provided by the Local Authority.

When the alarm is triggered the Scheme Manager during working hours or the Careline provider out
of hours will decide whether the call requires an emergency response from them or from the
emergency services. Essential resident information (information such as name, address, age, key
contacts including next of kin, medication, health issues, ethnicity) is collated at sign up to the service
by Peabody staff and transferred to the Careline provider. Peabody staff review customer data
quarterly or if there is a change in the tenants circumstances. The Scheme Manager updates the
Careline provider if anything significant has changed.

The out of hours Careline provider for Alleyn House is Islington Telecare. They are the only Careline
Provider we work with who did not provide a standardised form to complete containing resident
information. The custom and practice was to provide information about residents to Islington Telecare
by email. This practice had not resulted in any previous concerns about emergency response provided
by Islington Telecare.

Mrs Pamment

Mrs Pamment resided at Alleyn House for over 4 years, from June 2016 to August 2020. The support
agreement in place with Peabody was for Mrs Pamment to receive a call every morning when the
Scheme Manager was on site. Mrs Pamment’s daughter, provided support with shopping, and
household tasks such as cleaning, and visited her mother most days except Fridays.

Mrs Pamment was issued with a wrist pendant by Peabody in addition to the emergency pull cords in
each room throughout the flat which enabled 24 hour emergency help.

Mrs Pamment lived independently, she wore her care line pendant for emergencies but was also able
to contact the Scheme Manager during office hours directly if she had any particular queries or
concerns.

Timeline of events leading up to Mrs Pamment’s death

On the 12th August 2020 Mrs Pamment had a fall in the night and used her pendant to call Islington
Telecare. Islington Telecare visited at around 22.48 and reported that they found Mrs Pamment on
the floor. They assisted her off the floor, helped her back into bed and left. Later that night or the
following morning she fell again and was unable to call for assistance.

The next morning a Older People’s Housing and Support Manager was
providing cover for the Scheme Manager who was on leave. is familiar with the service and the
residents. As per our standard practice on arrival at the service [jjcommenced call checks to each of
the tenants. While carrying out these checks [ll noted that a resident in another flat was unwell. She
attended to this resident who required an ambulance. JJ waited with the resident until the

ambulance arrived. Once the customer had been seen by the paramedics, i carried on with her
checks and contacted Mrs Pamment'’s flat at 10.30am.

No answer was received from Mrs Pamment and Witherefore entered the flat and found Mrs
Pamment on the floor and extremely unwell. Hiiimmediately called for an ambulance and her
daughter who lived nearby and was very involved in Mrs Pamment’s support. Mrs Pamment was
admitted to hospital and sadly passed away a few days later.

Peabody

Review undertaken by Peabod

Following the incident es the Older People’s Housing and Support Manager, reviewed actions
required with her Head of Service. At that time no apparent failure to follow procedures nor concerns
regarding the response to the incident were identified. The review focussed on the actions taken by
the staff member when she arrived at work and the response when Mrs Pamment was found unwell

in her flat.

In terms of concerns raised by Mrs Pamment’s family at the time; the family was in contact with
after the event and questioned the actions of Islington Telecare. The family asked Hilsome questions
about Islington Telecare’s visit and | fee acted as an intermediary getting responses to those
questions. We were not contacted again by either Islington Telecare or the family on this matter and
so were not aware of any further issues or specific concerns in regards to Peabody's actions.

The question of whether an ambulance should have been called following Mrs Pamment’s first fall
became the focus of our reflection in preparing for the inquest. We were not alerted in advance to
concerns about our procedures and consequently our witnesses attended without representation.

Matters of Concern raised by the Coroner and Peabody's response

1. There was no record made by Peabody of the instruction given by Mrs P and her family.

It is agreed that the instruction to call Mrs Pamment’s daughter in the event of an incident was not
noted on Mrs Pamment’s case file so we cannot confirm if this instruction was given by Mrs Pamment
or her family. The staff member dealing with Mrs Pamment’s admission unfortunately does not recall
such an instruction due to the time passed since she moved in (over four years ago).

Our sheltered housing residents have capacity and can exercise choice. Our practice and protocol is
to ask residents if they wish their next of kin to be contacted as and when an incident occurs. In a
situation where the resident was incapacitated the staff member would always contact the resident's
next of kin/emergency contact and the emergency services where appropriate. A resident’s next of

kin would also be contacted where we are unduly concerned about a resident, using our best
judgment.

In order to address the concern raised, we have amended how we share residents’ information with
Islington Telecare to ensure that any specific requests are captured with the resident's permission and
noted to the Careline provider. We have also included a section that explains to the resident that if
Careline is alerted out of hours and the call requires an emergency response then the careline provider
will always contact their NOK unless the resident specifically opts out of that procedure.

All essentia} and required information will now be captured in a standardised ‘Resident Information
Form’. We have appended this form to our response.

Our service manager has made arrangements to meet all other careline providers we commission to

review the other forms in use to see if they could be improved. The outcome of those discussions will
further inform our procedural review.

3% Peabody *:

2. There was no Peabody protocol for the taking and recording such an instruction.

It is Peabody’s protocol to record essential information about the resident within our case
Management system. All residents are assessed as part of the moving in process and there is a
continuous process of review throughout their tenure. Information captured includes relevant history,
additional needs, next of kin details and other essential information such as medical information.

Not all information held about the resident is appropriate to share with the Careline provider and

therefore essential information, until this case, was either exchanged by form or by email in the case
of Islington Telecare.

As per the previous action above, we will now always use a comprehensive form to exchange essential
information with Careline providers and this will include any special instructions from the resident.

3. The Peabody scheme manager checked personal details with tenants from time to time, but was
never advised to obtain such an instruction regarding when to call a family member

Peabody's procedure requires our staff to review all resident’s personal details on a quarterly basis
or as and when the residents circumstances change. Significant changes are shared with the Careline
provider accordingly. This activity is reviewed by the Area Managers as part of their quarterly scheme
checks. This procedure was explained during the inquest.

As set out above, residents will now be informed that Careline will always contact NOK in an
emergency unless they opt out of that instruction. Further to that they will be explicitly asked whether
there are other special instructions they want shared with the Careline provider. We have produced
a Resident Information Form to capture all required information.

4. Peabody gave tenants’ personal details to Islington Telecare, but kept no record of what
information they had passed on to the alarm monitoring company. Witnesses in court had no idea
what Islington Telecare had been told to do in the event of an emergency with Mrs P.

We did not have this information available for the inquest as we were previously asked only to provide
a statement on Mrs Pamment’s accommodation and on the events of the day Mrs Pamment was
found unwell. Staff were not informed prior to the inquest that this information would be required
and no requests for further information were made to us beforehand, other than to provide the
witness statements as already noted.

In sheltered housing we have a set of information that we hand over to all Careline providers. We
informed the inquest that this information would ie include name, address, age, key contacts
i i in, medication, health issues and ethnicity.

st coi requested on a standard template provided by the Careline pe At
that time, Islington Telecare did not provide a template for this purpose. As confirmed catia ave
now produced a standardised template form which will be completed for each el wi
meeting with Islington on the 15'" March to further discuss the revised form and procedure.

Na
ox

Peabody =. on

5. Despite Mrs P’s death occurring in August 2020, it was not until today at inquest that Peabody
staff considered making any changes to their procedures.

We were not aware of the concerns raised by the family until our attendance at the inquest and our
own review had not identified any specific procedural or staff failings. Previous incidents had also not
highlighted gaps in our practice.

We accept that our procedures will be improved by a more formalised exchange of information with
Islington Telecare and by specifically giving residents the opportunity to have special instructions
captured by us and passed on to the out of hours service. Actions associated with this improvement
are either complete or set with an implementation date.

A meeting is due to take place on 15 March 2021 between in her role as Service Manager and her
counter-part at Islington Telecare whereby the roll out of the Resident Information form is to be
discussed so that the information on our residents provided to them is standardised. Forms for all
residents of Alleyn House are to be completed by 15 March and forms for residents of all other
schemes serviced by Islington Telecare are to be completed by end of March 2021.

Discussions with other careline providers regarding procedural changes are to take place by the end
of April 2021.

Summary of Actions taken/ to be taken by Peabod

e Astandard Resident Information Form for Careline providers has been produced (attached)
which captures appropriate information including specific instructions regarding family/NOK
contact in emergency and non-emergency situations.

e Anew procedure will be implemented that ensures that specific questions are asked of new
tenants and existing tenants at review and fully shared with all Careline providers supporting
Peabody residents. We will review all current resident information to ensure any special
instructions/arrangements are logged and communicated to the relevant Careline provider.

e As part of wider work and part of a review of Careline service, we are installing key safes for
each flat within Peabody’s Older Peoples’ Social Housing services to assist with access for
emergency services or appropriate persons.

We attach a copy of our Action Plan following this inquest for your reference.

We have also met with Islington’s Safeguarding Lead to discuss this case and there have been
communications between us and Islington Telecare since the inquest. As set out above, Peabody’s
Head of Service has meetings arranged with Islington Telecare and other telecare providers to review
our learning from this matter, which are to take place by the end of April 2021.

In terms of the inquest proceedings, it is also recognised that the witnesses from Peabody were not
appropriately supported when responding to and attending the inquest. Therefore Peabody is also
implementing a new process whereby there is appropriate senior management oversight for
involvement of Peabody’s staff in any future inquests.

¢,

¥ePeabody °=

We are concerned that the Coroner was not able to raise her concerns with Peabody on an informal
basis and request further information from Peabody in the first instance to give us an opportunity to
respond before a Regulation 28 report was considered; Peabody does however recognise the learning
and the room for improvement in regards to its record keeping, the sharing of information regarding
its residents to careline providers and communicating its expectations of careline providers. We hope
the above information provides the necessary assurance in regards to steps being taken by Peabody
resulting from this matter.

Please do let me know if we can assist you any further and we would like to again offer our sincere
condolences to Mrs Pamment’s family.

Yours sincerely

Mili
Group Director Care and Support

cc:
HR slington Safeguarding Lead

| Regulator of Social Housing

Encl.
e Appendix 1 - Resident Information Form

e Appendix 2 - Peabody’s Action Plan