Ann Stillwell

Your ref:  

29 January 2021 

Mr Graeme Irvine 
Area Coroner East London 
Walthamstow Coroners Court 

By email to:  

Dear Mr Irvine  

6th floor, North House 
St Edwards Way 
Romford 
RM1 3AE 

Tel: 

Re: 

Inquest touching upon the death of Mrs Ann Doris Stillwell, Regulation 28 
Report 

I write in response to the Prevention of Future Deaths Report issued to Havering Clinical 
Commissioning Group on the 8 December 2020, following the Coroner’s inquest into the death 
of Mrs Ann Doris Stillwell. 

The CCG director lead and head of service have met to discuss the Coroner’s concerns set 
out in the Regulation 28 report and agreed actions to strengthen the management of requests 
for 1 to 1 care by care providers.   

Some changes to the process had been introduced in November 2020 which will reduce the 
risk of a similar incident occurring again and some additional actions have been agreed for 
implementation in February 2021. 

Please find attached a report for the Coroner on the actions that have been taken.  

The CCG strives to learn from incidents and to constantly improve the service provision it 
provides.  Please do not hesitate to contact me if you require any clarification. 

Thank you for your helpful insights into this case. 

Yours sincerely  

Managing Director 

cc: 

 Director of Public Health, London Borough of Havering 

Attachment:  REGULATION 28:  Report to Prevent Future Deaths from Graeme Irvine, Area  

Coroner East London, 8.12.20. 

Accountable Officer: 
Managing Director: 
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups 

Chairs:  
Dr 
Dr 
Dr 

, Barking and Dagenham Clinical Commissioning Group 

, Havering Clinical Commissioning Group 

 Redbridge Clinical Commissioning Group 

 
 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Response to:             REGULATION 28:  Report to Prevent Future Deaths from 

Graeme Irvine, Area Coroner East London, 8.12.20. 

From:                          

, Managing Director, BHR CCGS  

Date:                          29 January 2021  

1.  This report provides a response to the Report to Future Prevent Deaths from 

Graeme Irvine, Area Coroner East London, of 8.12.20.    

2.  Barking and Dagenham, Havering and Redbridge CCGs have reviewed the 

Coroner’s concerns in the report relating to the death of Ann Doris Stillwell.  We 
have identified that there are some improvements that could be made to the 
processes within the NHS Continuing Healthcare Team to strengthen the 
decision-making process for 1 to 1s.  

3.  The process we had been following for managing requests for 1 to 1s required 
the hospital discharge team to send the referral directly to the NHS CHC team 
prior to discharge, where this has been requested by the care home. Whilst we 
believe that the need for 1 to 1 was not flagged up on the care plan for Mrs 
Stillwell, this should have been considered as Mrs Stillwell was having an 
enhanced level of monitoring in hospital. The fact that the nursing home queried 
this before discharge should have prompted the staff member from the 
brokerage team to alert a clinician to the possible need for 1 to 1.  

4.  We have identified that requests for 1 to 1s come through to different people in 
the CHC Team and the level of information given is sometimes variable. We 
have now introduced a requirement for requests for 1 to 1s to be sent to the 
Head of Service and a senior nurse assessor who will provide a response to the 
request within 2 hours. 

5. 

If the information is not complete, then the hospital discharge team is asked to 
forward all falls risk assessments, care diaries and behaviour charts as 
appropriate to the Head of Service or senior nurse assessor so that they can 
confirm a decision. Evidence is needed as to whether this level of support is 
required during the daytime only or the full 24 hours. Many people are nursed on 
enhanced observations or in a cohort /bay in hospital do not go on to require this 
level of support in the care home. 

6.  The Head of Service/senior nurse assessor will take a view based on the 

information received and ask for further evidence if required. The authorisation 
for 1 to 1s is normally given for 14 days and prior to this point we request, via the 
hospital discharge team, that the care home provides further evidence to warrant 
any extension of the 1 to 1. This system has been in operation since November 
2020 and appears to be working well. 

7.  We are introducing an additional safeguard to ensure that any requests for 1 to 
1s submitted to the brokerage team directly by a care home are brought to the 
attention of a senior clinician. The following actions have been agreed: 
• 

To confirm with all non-clinical brokerage staff the need to escalate to a 
clinician where 1:1 care is requested by a care provider – With immediate 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 effect - and to ensure that this is built into CHC processes. By end 
February 2021 to ensure this is built into our electronic systems. 

• 

To ensure all staff are reminded of the need to activate their out of office 
messages and that these should indicate a suitable alternative person who 
can respond. Where this is a clinician an alternative clinician should be 
named as contact. With immediate effect. 

8.  Please note that the report was copied to 
Health for London Borough of Havering.   

, Director of Public 

2

Mr Graeme Irvine  
HM Area Coroner, East London  
Walthamstow Coroners Court  
Queens Road  
London E17 8QP  

Dear Graeme,  

From Helen Whately MP 
Minister of State for Care 

39 Victoria Street 
London 
SW1H 0EU 

 03 March 2021 

Prevention of Future Deaths: Ann Doris Stillwell 

Thank you for your letter of 8 December 2020 concerning the death of Ann Doris Stillwell, 
which came to the attention of the Department on 8 January 2021.  I am responding as 
Minister with responsibility for continuing healthcare and I am grateful for the additional 
time in which to do so.   

Firstly, I would like to offer my sincere condolences to Mrs Stillwell’s family.  Ministers are 
committed to ensuring residents in care homes receive high quality and safe care.  I am 
grateful that you have brought these matters in relation to Mrs Stillwell’s death to my 
attention.  

As you are aware, the Department for Health and Social Care is responsible for Continuing 
Healthcare policy and in 2018, published the revised National Framework for NHS 
Continuing Healthcare and NHS-funded Nursing Care1.  The guidance sets out in 
paragraphs 165-180 where responsibility for care planning, commissioning services and 
case management lies. This includes that clinical commissioning groups (CCGs) should 
operate a person-centred approach to ensure a care package is tailored to meet the needs 
of the individual.   

CCGs are responsible for the commissioning of 1:1 care within their local 
areas.  I understand that Barking and Dagenham Havering, and Redbridge CCGs, have 
provided a joint response which sets out the actions taken to learn from the findings 
presented, following Mrs Stillwell’s death.  

This action includes a requirement for requests for 1:1 care to be sent to the Head of 
Service and a senior nurse assessor who will provide a response to the request within two 
hours.  The CCGs’ response also sets out further steps to escalate requests to appropriate 
clinician level staff, where required.   

The Department has considered the concerns raised in your report and in this instance, we 
do not consider that a change in national policy is required.   However, Departmental 
officials will work with NHS England, which is responsible for providing assurance on the 
actions of CCGs, to consider the specific circumstances of this case and whether further 
regional monitoring may be required.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
 I hope this response is helpful.  

HELEN WHATELY