Ruth Jones

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

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

4 June 2021 

Dear HM Senior Coroner Alison Mutch OBE 

Prevention of future death report following inquest into the death of Ruth Jones 

Thank you for sending us a copy of the prevention of future death report (Regulation 28) 
issued following the sad death of Ruth Jones. Our condolences are with the family and 
friends of Mrs Jones.  

We  note  the  legal  requirement  upon  the  Care  Quality  Commission  to  respond  to  your 
report within 56 days, by 08 April 2021. 

The role of the CQC & Inspection methodology  

The CQC was established on 01 April 2009 by the Health and Social Care Act 2008 (‘the 
Act’). The CQC is an independent regulator of healthcare, adult social care, hospital and 
community trusts and primary care services in England. 

From 01 April 2015, the CQC has had the lead responsibility for investigating and where 
appropriate  prosecuting  breaches  of  fundamental  care  standards  contained  within  the 
Health  and  Social  Care  Act  2008  (Regulated  Activities)  Regulations  2014  (“the  2014 
Regulations”) 

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.   

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, corroborate evidence and 
obtain  reassurance  of  how  the  provider  performs  against  characteristics  of  ratings. 
Furthermore,  Inspectors  obtain  information  as  to  how  risks  to  people  are  identified, 
assessed and mitigated. Sources of evidence for the KLOEs can be found on our website 
along with the 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 2014 Regulations.  

Regulatory History 

Meridian Healthcare Limited was registered to provide regulated activity at The Beeches 
on 17 November 2011.  

Prior to registering a provider, the CQC registration team carry out relevant checks and 
interviews to assess the provider’s suitability to be admitted onto the register. In order to 
continue  assessing  the  provider’s  compliance  with  the  Regulations,  and  the  Act, 
inspections are undertaken.  

CQC’s  last  comprehensive  inspection  of  The  Beeches  (published  3  March  2018)  the 
service was rated as Good and there were no breaches of regulation. The Beeches had 
been rated Good at its previous inspection (published 08 October 2015).  

You  can  find  a  copy  of  both  of  the  above-mentioned  reports  on  our  website  at 
https://www.cqc.org.uk/location/1-123208300 

Relevant Background 

Mrs Jones was admitted to  The Beeches on 16 April 2018.  The Beeches is a location 
registered with CQC at Yew Trees Lane, Dukinfield, Tameside, SK16 5BJ. The registered 
provider  in  operation  of  The  Beeches  at  the  time  of  Mrs  Jones’  death  was  Meridian 
Healthcare Limited. The provider is registered for the regulated activity: Accommodation 
for persons who require nursing or personal care. There are conditions on the registration 
for  this  location,  namely  the  registered  provider  must  not  provide  nursing  care  under 
accommodation for persons who require nursing or personal care at The Beeches; and 
the registered provider must only accommodate a maximum of 32 service users at The 
Beeches.  The  registered  manager  at  the  time  was 
who  has  been 
registered as the registered manager of The Beeches since 1 October 2010.   

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Statutory notification in relation to the death of Mrs Jones. 

On the 23 June 2020, The Beeches submitted a Statutory Notification in relation to CQC 
in  relation  to  the  fall  experienced  by  Mrs  Jones  on  17  June  2020,  in  accordance  with 
Regulation  18  Care  Quality  Commission  (Registration)  Regulations  2009  (“the  2009 
Regulations”). This notification detailed that Mrs Jones had sustained a fractured left hip. 
Having reviewed this notification we were satisfied with the measures The Beeches had 
put in place to mitigate risk of falls for Mrs Jones as much as possible and the action that 
had been taken subsequent to the fall.  

On the 17 June 2020 Mrs Jones had become unwell and medical advice was sought from 
Digital  Health.  A  diagnosis  of  suspected  Covid-19  was  made,  and  Mrs  Jones  was 
subsequently supported to isolate in her bedroom, in line with government guidance at 
that time. Mrs Jones was barrier nursed in her bedroom with the support of one to one 
staffing due to her presentation although she was not funded for this level of support. At 
approximately 4:30pm the staff member stepped out of the bedroom. They returned in 
response to the nurse call alert mat sounding and found Mrs Jones on the floor next to 
her chair. Following checks by senior staff, Mrs Jones later began to display discomfort 
and  emergency  medical  assistance  was  called.  Paramedics  attended  to  Mrs  Jones  at 
The Beeches at approximately 7pm that evening and she was transferred by ambulance 
to  Tameside  General Hospital.  Mrs Jones  sadly passed  away  in  the  early  hours of  21 
June 2020. 

We note the cause of death to be: 
1a) Bronchopneumonia 
II) Frailty, Dementia, Hypertension, Fractured Neck of Femur 

Matters of concern for CQC 

Upon receipt of the concerns raises as part of the Regulation 28 report issued to CQC by 
the coroner an unannounced targeted inspection of The Beeches was undertaken. This 
was completed to ensure that the circumstances of Mrs Jones death did not raise any 
ongoing risk to people currently living at the home.   

The inspection commenced on 25 February 2021. The inspection team consisted of one 
inspector. The inspection was focused on one key question; Is the service Safe? Within 
the Safe domain the inspection targeted the Key Line of Enquiry: How are risks to people 
assessed and their safety monitored and managed, so they are supported to stay safe 
and their freedom is respected? 

We focused on the specific areas raised in the Regulation 28 report. We looked at the 
assessment,  monitoring,  management  of  falls  and  arrangements  for  people  requiring 
transfer to hospital for assessment and health care interventions.  

We also looked at infection prevention and control (IPC) as part of a thematic inspection 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 methodology CQC is undertaking as a result of the response to the Covid-19 pandemic. 
This was reported under the key line of enquiry; Preventing and controlling infection.  

We found the service had suitable processes in place to assess people’s individual risk 
and addressed a wide variety of factors when considering what measures could be put in 
place  to  mitigate  risk  where  possible  whilst  respecting  an  individual’s  preferences  and 
choices.  Where  accidents  and  incidents  had  occurred,  these  were  investigated  to 
understand how it happened. Action was taken to reduce future risk and share learning 
across  provider  services.  Hospital  passports,  which  contained  information  about  an 
individual’s support needs, risk and medications were in place. These passports would 
be sent with service users attending hospital as part of the ‘red bag scheme’ the service 
participated in.  

CQC understands that the ‘red bag scheme’ is a national initiative designed to support 
care homes, ambulance services and the local hospital meet the requirements of NICE 
guideline  NG27:  Transition  between  inpatient  hospital  setting  and  community  or  care 
homes. 

The specific matters of concern raised by the coroner in the Regulation 28 report issues 
to CQC are:  

1)  The inquest heard that Mrs Jones was frail and at risk of falls. The home had a 
falls  risk  plan in  place  that was  based around her  being  observed during the 
day  in  communal  areas.  The  home  was  not  staffed  to  provide  one  to  one 
observations for residents required to self-isolate. As a result, when Covid 19 
was suspected by the GP, and the home were directed to isolate her she could 
not be observed by staff as would generally be the case in the day. The home 
took some steps with sensors to ensure they were aware if she stood up whilst 
in her room but could not provide continuous observation. It was unclear how 
homes  were  being  advised  to  safely  manage  residents  at  risk  of  falls  where 
isolation  was  required.  The  home  were  unaware  of  any  guidance  that  they 
should follow to manage the risk. 

In accordance with CQC’s regulatory remit, 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.  

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  the 
National Institute for Health and Care Excellence “NICE” and the Social Care Institute for 
Excellence “SCIE”). We expect registered persons to keep up to date with, take on board 
and implement good practice standards provided by relevant authoritative organisations.  

NICE provide a variety of guidance regarding best practice for the management of falls in 
care  homes.  This  includes  Assessment  and  prevention  of  falls  in  older  people 

4 

 
 
 
 
 
 
 
 
 
 
 
 https://www.nice.org.uk/guidance/cg161/evidence/falls-full-guidance-190033741;  falls  in 
older  people  https://www.nice.org.uk/guidance/qs86/resources/falls-in-older-people-pdf-
2098911933637. We are not aware of any specific guidance in relation to falls prevention 
for people isolating due to Covid-19.  

At the time of Mrs Jones fall on 17th June 2020 there was Government guidance in place 
regarding the admission and care of residents in a care home during COVID-19 which 
was  being  followed  by  staff  at  The  Beeches.  Government  guidance  included  
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachmen
t_data/file/957296/Care_homes_guidance_updated.pdf  and  a  variety  of  guidance  in 
relation to  COVID-19: how to work safely in care homes 
https://www.gov.uk/government/publications/covid-19-how-to-work-safely-in-care-
homes.  

The responsibility lies with the provider to ensure they have suitable processes to assess 
and provide appropriate support to people they support with regulated activity.   

We have reviewed Mrs Jones’ care records, and in this case, we believe that the service 
had taken all reasonable steps to mitigate the risk of falls for Mrs Jones. There were care 
plans in place to manage the risk of falls for Mrs Jones and these were relevant whether 
she was in communal areas or in her bedroom.  Reference to times when Mrs. Jones was 
unwell were made and indicated that staff should make additional checks of Mrs Jones’ 
welfare at those times. In our view, the registered manager had assessed Mrs Jones on 
an individual basis and despite her not being funded for one to one care had assessed 
risk and put measures in place to support Mrs Jones whilst she was unwell.   

2)  When Mrs Jones had to go to hospital she was sent alone and her family could 
not go with her due to Covid 19 restrictions. The inquest heard that Mrs Jones 
was  frail  and  vulnerable.  The  inquest  was  told  that  the  unsupported 
presentation/assessment of vulnerable, frail and elderly patients such as Mrs 
Jones  presented  significant  problems  to  clinicians  in  terms  of  effective 
communication and understanding their health baseline to support appropriate 
and timely clinical decision making.  

NICE  guidance  includes  Moving  between  hospital  and  home,  including  care  homes. 
https://www.nice.org.uk/about/nice-communities/social-care/quick-guides/moving-
between-hospital-and-home-including-care-homes.  

The Beeches participated in the red bag scheme. This is a national scheme that assists 
care home residents admitted to hospital to be discharged quicker. The bags contain key 
paperwork (hospital passport), medication and personal items like glasses, slippers and 
dentures.  The  hospital  passport  contained  relevant  information  about  the  individual’s 
current  needs,  a  brief  medical  history,  as  well  as  important  contact  details  and  other 
relevant  information  about  a  person’s  preferences.    These  are  handed  to  ambulance 

5 

 
 
 
 
 
 
 
 
 
 
 
 
 crews by carers and travel with patients to hospital where they are then handed to the 
doctor. This process is designed to ease the transfer of people between care homes and 
hospitals and should have alleviated the concerns described during the inquest into the 
death of Mrs. Jones. The Beeches confirmed that the red bag scheme which included the 
hospital passport was used that day as part of the transfer of Mrs. Jones to the hospital.  

Whilst this does not appear to indicate any required actions by Tameside and Glossop 
Integrated Care NHS Foundation Trust (“the Trust”), we have reviewed this regulation 28 
report in conjunction with CQC colleagues from the acute hospitals directorate to enable 
CQC  to  provide  a  holistic  response.  We  are  aware  that  the  Trust  has  a  digital  health 
service that is in use within all care homes in Tameside and Glossop to aid communication 
between the acute hospital, care homes and GPs. This service enables care home staff 
to readily exchange information with the acute trust and share health data for individual 
care home residents.  

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  The Beeches, we are continually monitoring the 
service and liaising with the local authority to review any ongoing risks and feedback. 

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 inspection the systems and processes being 
operated  by  those  services  it  regulates.  CQC  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 

6

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

From Helen Whately MP 
Minister of State for Care 

39 Victoria Street 
London 
SW1H 0EU 

03 June 2021  

Dear Ms Mutch,  

Thank you for your letter of 11 February 2021 about the death of Ruth Jones.  I am 
replying as the Minister with responsibility for adult social care and I am grateful for the 
additional time in which to do so.  

I would like to begin by saying how saddened I was to read the circumstances of Mrs 
Jones’s death and I offer my condolences to her family.    

I can appreciate how deeply upsetting it must be for her family that they were unable to 
accompany Mrs Jones to hospital during the emergency period of the COVID-19 
pandemic.  I understand your concern about the potential impact this could have on 
outcomes for vulnerable people if hospital clinicians have reduced information available to 
them.    

Patient safety is our top priority, which is why the NHS has stringent infection control 
measures in place to prevent the spread of coronavirus to vulnerable hospital 
patients.  This includes managing visits in a safe and COVID-secure way.    

However, the Government also recognises the importance of being able to visit family, 
friends and loved ones in hospital.    

At the time of Mrs Jones’s admission to hospital in June 2020, guidance issued by NHS 
England limited the number of visitors at the bedside to one close family contact or 
somebody important to the patient.  However, where it was possible to maintain social 
distancing throughout a visit, a second additional visitor was permitted in certain 
circumstances; including a family member for individuals receiving end-of-life care.    

On 16 March 2021, NHS England and NHS Improvement revised its guidance on how 
NHS organisations may choose to facilitate visiting across healthcare inpatient, outpatient 
and diagnostic service settings during the COVID-19 pandemic.  Careful visiting policies 
remain appropriate while coronavirus continues to be in general circulation, and the 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
  
 number of visitors at the bedside is limited to one close family contact or somebody 
important to the patient.  Organisations can exercise discretion where COVID-19 rates are 
higher, and the health, safety and wellbeing of patients, communities and staff remains the 
priority.   

I am informed that the response you have received from the Care Quality Commission 
(CQC), explains that the Beeches Care Home, where Mrs Jones resided, participates in 
the ‘red bag’ scheme1, a national initiative to support the provision of important information 
when a person with social care needs transitions between inpatient hospital settings and 
community or care homes.  This includes a ‘hospital passport’, which contains information 
about an individual’s support needs, risk and medications.  I understand that a ‘hospital 
passport’ accompanied Mrs Jones when she was transferred to hospital.     

In addition, I am advised that all care homes within Tameside and Glossop have access to 
a digital health service that aids communication between the care homes, the acute 
hospital and GPs, enabling care homes to share information about individual care home 
residents that may have been transferred to a difference care setting.   

You may also wish to note that guidance in April 2020, Coronavirus (COVID-19): 
admissions and care of people in care homes2, contained a link to RESTORE23, a physical 
deterioration and escalation tool for care and nursing homes, as well as guidance on 
managing COVID-19 in care homes, published by the British Geriatrics Society4.  These 
sources provide clear guidance on the importance of providing a concise escalation history 
to health professionals to support their professional decision making, and advance care 
planning.  Reference is also made in the guidance to Enhanced Health in Care Homes5, a 
new, proactive model of care, centred on the needs of the individual.    

Departmental officials will take action to highlight the links to RESTORE2 and the British 
Geriatrics Society guidance more explicitly within the Coronavirus (COVID-19): admissions 
and care of people in care homes guidance to raise greater awareness and reduce future 
challenges faced by clinicians supporting care homes.   

In relation to the guidance that is available to care homes on safely managing residents at 
risk of falls who are advised to self-isolate, since the start of this pandemic, the 
Department has worked closely with the social care sector, along with public health 
experts, including Public Health England (PHE) and NHS England and NHS Improvement 
(NHSEI), to put in place guidance and support for adult social care.   

Our priority for adult social care is for everyone who relies on care to continue getting the 
care they need throughout the COVID-19 pandemic.  COVID-19 continues to present an 
unprecedented challenge for social care.  

Under the Health and Social Care Act 2008 (Regulated Activities) Regulations 20146, care 
homes have a statutory duty to ensure safe care and treatment for service users.  This 
includes assessing the risks to the health and the safety of service users in a manner that 
is reasonably practicable to mitigate any such risks.   

Extensive guidance is available on best practice on safely managing residents at risk of 
falls.  Specifically, the guidance Falls and Fractures: applying All Our Health7 (which 
includes links to NICE standards), should continue to be followed at all times, including 
during the COVID-19 outbreak.  This guidance was last updated in January 2020.  

  
  
  
  
  
  
  
  
 As mentioned earlier in this response, in April 2020, we published Coronavirus (COVID-
19): admissions and care of people in care homes, which was co-produced with PHE, 
CQC and NHSEI, to provide guidance to care homes on self-isolation of care home 
residents.  The guidance reiterates the need for care homes to carry out their own risk 
assessments when considering the implications of the guidance.  Departmental officials 
will take action to include a link within this guidance to the Falls and Fractures 
guidance.  The Department will also seek further clarification from PHE and NHSEI of any 
adjustments that the Falls and Fractures guidance might require when care home 
residents are self-isolating.    

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

HELEN WHATELY