Rachel Johnston

Worcester road

                                                                                                                    Pirton,
                                                                                                                    Worcester
                                                                                                                    WR8 9EF

Pirton Grange Specialist Care Centre 

HM Coroner Senior David Donald William Reid
Worcestershire Coroner
The Civic  
Martins Way 
Stourport on Severn 
DY13 SUN

Dear Mr Reid

Inquest touching on the death of Rachel Johnston

Response to Regulation 28 Report

25 May 2021

We refer to the Regulation 28 of the Coroners (Investigations) Regulations 2013 Report issued by HM 

Senior  Coroner,  David  Donald  William  Reid  following  the  investigation  into  the  death  of  Rachel 
Bernadette Johnston. This response is provided on behalf of Pirton Grange Specialist Services (‘the 

Home’). The Home is committed to the care, safety, and well-being of its service users.

Matters of Concern for HM Coroner

1. Following  Rachel's  death,  there  appears  to  have  been  no  adequate  internal  investigation  or 

disciplinary  procedure  which  was  able  to  identify  the  gross  failings  of  the  nurses  mentioned 

above.  Accordingly, both nurses continued working at Pirton Grange for some time, without 

any action being taken to ensure that patients were not put at risk by their actions. Furthermore 

e,  no  effort  was  made  to  report  the  conduct  of  the  nurses  concerned  to  the  Nursing  and 

Midwifery Council (‘NMC’), the appropriate regulatory body, until February 2021, over 2 years 

after Rachel's death. 

Following Rachel’s death, the Home introduced training for all nurses, reviewed its policies to ensure 

that there would be a consistent approach across the board.

Those concerned in carrying out the initial investigation believed that they had identified training issues 

and arranged for appropriate training to be provided.  The Home became fully aware of the significance 

of the physiological observations on Rachel after her discharge following the dental surgery when it 

received the expert report prepared by Dr 

.  The Home received this on 3 September 2020. 

In the interim period, the Home had discussions with the CQC, was involved in Learning Disabilities 

Mortality Review Programme (LeDer) meetings and was also in receipt of legal advice.  At no time did 

anyone raise the issue that any member of staff should be reported to their professional body including 

the NMC.  However, on full consideration of Dr 

 report, the Home informed the Agencies 

that it did not want either nurses to work for it again. This was in early January 2021.    

2. Even now, there appears to be no Policy in place at Pirton Grange which sets out a suitable 

and robust procedure for:

                                                                                Worcester road

                                                                                                                    Pirton,
                                                                                                                    Worcester
                                                                                                                    WR8 9EF

Pirton Grange Specialist Care Centre 

a.

identifying and investigating possible misconduct by nursing staff, e.g. where they have 

ignored a Policy;

b.

imposing  an  interim  suspension  on  a  member  of  the  nursing  staff,  pending  the 

completion of such an investigation, if in the interests of ensuring the ongoing safety of 

residents;

c.

if appropriate after the investigation has been completed, ensuring that member of the 

nursing staff does not work at Pirton Grange again; and

d.

if the internal investigation has identified likely misconduct, reporting that member of 

the nursing staff to the NMC.

As result of the HM Coroners concerns the Home has made its procedures more robust. This includes 

independent oversight to identify and investigate possible misconduct by staff, including nursing staff.  

This  comprises  of  the  engagement  of  a  Solicitor’s  firm  on  a  retainer  basis  to  provide  general 

employment advice, support on all HR matters and assistance and oversight with and/or advising on 

any  investigation,  disciplinary  matters,  and  considering  whether  any  reports  to  professional  bodies 

should be made. The Home will engage its Solicitors at the very outset where there is an issue which 

may give rise to any misconduct issues by staff.

The  Home  has  also  recently  changed  its  Registered  Manager/Nominated  Individual.  The  new 

nominated individual has introduced a Quality Assurance Audit to take place quarterly. This audit follows 

the  same  quality  standards  investigated  by  the  CQC  as  part  of  its  assessment  (i.e.  Key  Lines  of 

Enquiries). The CQC and local CCG, who place service users at the Home, will also continue to inspect 

the Home on a regular basis. 

Enclosed alongside this letter are relevant policies from the Staff Handbook, namely: 

1. Conduct and Standards Policy

2. Disciplinary Policy and Procedure

3. Handling and Security of DBS Disclosure Information Policy

4. Performance Management Policy

5. Professional Boundaries Policy

6. Safeguarding Service Users from Abuse or Harm

7. Staff Retention Policy

The Staff Handbook was prepared by an external company and was been in place prior to Rachel’s 

death. The Staff Handbook is regularly reviewed and updates are communicated to all staff. All staff 

are taken through the Staff Handbook on induction. The Staff Handbook is made available to all staff, 

both employed and agency in the Home. 

Conduct and Standards Policy

The Home’s Conduct and Standards policy, which applies to all staff (including agency workers) sets 

out what is expected from its staff in terms of the provision of care so that it is safe, effective, caring and 

responsive to the service user’s needs. Staff are required to comply with the standards of conduct and 

                                                                                Worcester road

                                                                                                                    Pirton,
                                                                                                                    Worcester
                                                                                                                    WR8 9EF

Pirton Grange Specialist Care Centre 

practice of their respective occupation or professions and comply with the Home’s Operating Policies 

and Procedures. This policy provides that if there is a failure to provide the required care resulting in 

any  harm  or  near  miss  of  harm,  then  this  will  treated  as  misconduct,  and  will  be  fully  investigated, 

instigating a disciplinary/performance management procedure. It also sets out that this may result in a 

report being made to a professional body in respect of the staff concerned.   

This Policy sets out examples of care which fall below the required standard, such as omitting to carry 

out sufficient observations (check-ups, physiological observations), omitting to call emergency services 

or external support when necessary. 

It also includes a non-exhaustive list of actions which are considered to constitute gross misconduct, 

this includes, serious or gross negligence and serious breach of policies and procedures. This policy 

also covers the consequences of failing to provide adequate care.

Disciplinary Policy and Performance Management Policy

The  Disciplinary  Policy  applies  to  the  Home’s  employees  and  addresses  the  Home’s  disciplinary 

procedures and sanctions. The Policy also addresses interim suspension from work, which is immediate 

if  a  service  user  has  been  seriously  harmed,  or  if  there  a  risk  to  service  user  safety.  The  possible 

sanctions include dismissal.

The Performance Management Policy, which applies to all staff (including agency workers) deals with 

how the Home investigates adverse events, near misses, staff performance, competence and conduct 

issues.    The  policy  also  covers  the  outcomes  and  sanctions  and  is  to  be  considered  alongside  the 

Home’s Disciplinary policy. 

In accordance with the Performance Management Policy, if a service user has suffered significant harm 

or there is a risk to service user safety, then the Home’s Senior Management team, in conjunction with 

the Quality Assurance Manager and external advisors will implement: -

•

•

Immediate  suspension  of  the  member/s  of  staff  involved,  including  agency  staff,  with 

notification to the agency, or other relevant party (if appropriate), that the worker is being 

investigated for possible misconduct/lack of competence.

Immediate referral of the member(s) of staff involved on determination that the issue is one 

of lack of competence or misconduct to regulatory or other bodies, such as the NMC or 

GMC, in accordance with fitness to practice requirements.

In terms of procedure to be followed in respect of disciplinary considerations, the employment status of 

the individual dictates how the Home deals with any resulting action. In respect of employees of the 

Home, where misconduct is both contemplated and/or identified, there is a HR procedure to be followed 

in line with the Home’s Disciplinary Policy and Procedure which includes suspension of the employee 

during  an  investigation.  If  the  investigation  concludes  misconduct,  disciplinary  actions  can  result  in 

dismissal  of  the  employee.  Furthermore,  the  Home  will  report  the  employee  to  the  appropriate 

professional body on concluding that there has been misconduct in accordance with the Professional 

Boundaries policy.

                                                                                Worcester road

                                                                                                                    Pirton,
                                                                                                                    Worcester
                                                                                                                    WR8 9EF

Pirton Grange Specialist Care Centre 

In  relation  to  agency  staff,  where  the  agency  worker  is  part  of  an  investigation  (internal,  poor 

performance or disciplinary investigation) in which their conduct may be called into question, the Home’s 

Staff  Retention  policy  states  that  it  shall  not  use  their  services  and  shall  notify  the  agency  that  the 

agency  worker  shall  not  carry  out  any  work  for  the  Home  until  the  investigation  is  completed.  If  the 

investigation concludes misconduct, the agency will be informed that the agency worker is not permitted 

to carry out any future work for the Home again. Furthermore, the Home will report the agency worker 

to the appropriate professional body on concluding that there has been misconduct.

Professional Boundaries Policy

The Home’s Professional Boundaries policy provides that care, nursing and any other professional staff 

must comply with the standards of conduct and practice for their respective profession/occupation.  The 

policy sets out that where the Home’s investigation concludes a finding of misconduct of any member 

of staff, a report will be made to the relevant professional body.

The Home feels that all of the measures outlined above will effectively deal with the areas of concern 

raised  by  HM  Coroner.    We  trust  that  this  response  is  to  the  satisfaction  of  HM  Coroner  as  to  the 

procedures  in  place  at  the  Home  which  will  ensure  that  any  failures  are  identified  which  have  the 

potential of leading to risk of service user safety.

Should HM Coroner have any further queries arising from this response, we will be happy to assist.

We would also like to take this opportunity to express, once again, the Home’s sincere condolences to 

Rachel Johnston’s family and friends for their loss.

Yours sincerely

CEO

Holmleigh Care Homes Limited