Pauline Brumfitt

In the matter of the inquest into the death of Pauline Brumfitt  

THE RESPONSE OF ANCHOR HANOVER GROUP TO THE 
PREVENTION OF FUTURE DEATHS REPORT DATED 6 APRIL 2021 

The Anchor Hanover Group (“we” and “our”) writes further to the Prevention of Future Deaths 
Report  made  by  the  HM  Senior  Coroner  pursuant  to  Regulation  28  of  the  Coroners 
(Investigations) Regulations 2013 (the Regulations) dated 6 April 2021 (the PFD Report).  

Within the PFD report, the HM Senior Coroner raises three matters of concern as follows: 

(1)  The  policies  and  procedures  in  existence  at  the  care  home  pertaining  to  falls  risk 
assessment and prevention were not applied to Pauline Brumfitt as they should have 
been; 

(2)  Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take 
appropriate action to prevent further falls were not taken as they should have been; 
and 

(3)  The matter was not reported to the regulatory bodies, an investigation had not been 
commenced  at  the  time  of  the  inquest  and  staff  supervision/discussion  re  falls 
prevention only commenced in February/March 2021. Appropriate timely action could 
have helped to prevent future deaths in similar circumstances. 

Before  providing  our  substantive  response  to  these  concerns,  we  would  like  to  offer  our 
sincere and heartfelt condolences to the family of Mrs Brumfitt.   

We also wish to express our disappointment at the decision to issue a PFD Report in this case 
and repeat our position, as explained in our letter to the HM Senior Coroner dated 28 March 
2021, that the requirements of Regulation 28(3) of the Regulations were not met.  We were 
not  afforded  a  proper  opportunity  to  provide  any  explanation  in  relation  to  the  matters  of 
concern raised both during the inquest and within the PFD Report.  

The only witness called to give evidence on our behalf was a witness of fact to the falls (despite 
having  not  been  present  at  the  time)  and  who  was  not  properly  qualified  to  explain  the 
supervisory  measures  that  exist,  across  our  organisation,  above home level.  Had  we been 
given  the  chance  we  could  have  put  forward  a  witness  to  explain  our  procedures  to  the 
satisfaction of the HM Senior Coroner. In failing to make any such enquiry, the inquest did not 
have  proper  consideration  of  all relevant matters  and,  noting the requirements  of the  Chief 
Coroner’s  Guidance  Number  5  (Reports  to  Prevent  Future  Deaths)  did  not  meet  the  pre-
conditions to the ordering of a PFD Report.   

We do not dispute that there was a failing on the part of staff within the care home to follow 
the  extensive  falls  management  procedures  in  place.  It  appears  there  were  a  number  of 
shortcomings within the home around falls management and we do not seek to excuse these. 
It has come to light as part of our investigation into relevant events that a small number of staff 
within the home had developed an internal culture lacking in the level of transparency that we 
demand and expect. This is extremely disappointing.   

A deliberate failure on the part of senior management within the home to properly record and 
report incidents is the reason why we had commenced no investigation until March this year. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In short, we were unaware of this matter until receipt of correspondence from the HM Senior 
Coroner  on  3  March  2021.  In  light  of  the  deliberate  actions  of  the  individuals  involved  it  is 
questionable  as  to  how,  even  with  the  most  intrusive  level  of  oversight,  we  would  have 
identified this.  

Disciplinary proceedings have been initiated against those involved. The Home Manager was 
suspended  pending  disciplinary  action  and  has  since  failed  to  engage  with  the  disciplinary 
process. She has now resigned and a Disclosure and Barring Service (DBS) referral has been 
made. The Local Authority Safeguarding team have been notified.   

Turning to the specific matters of concern raised in the PFD Report.  

Falls risk - policies and procedures 

We have extensive falls management policies and procedures that apply across all of our care 
homes. Upon admission to one of our homes, all residents are required to be assessed for 
falls risk and the outcome recorded in a falls risk assessment. Where deemed to be at risk of 
falls the resident will have a falls prevention plan (FPP) put in place. Staff in our homes work 
closely with GP services and are aware of how to refer to the local authority falls team, where 
necessary, to ensure that healthcare professionals actively support the home in developing 
the highest possible standards of FPP.  

Our falls management procedures have been continually enhanced and subject to rigorous 
scrutiny. They include: 

a)  Detailed  guidance  through  our  “Personal  Planners  Toolkit”  which  explains  how  to 
develop each resident’s care plan and our expectations as to how information should 
be  recorded  within  it.  Care  plans  and  any  risk  assessments  (including  falls  risk 
assessments) must be reviewed monthly by care staff as a minimum. Within the Toolkit 
is a clear explanation of what we require to be recorded in the mobility care plan, falls 
risk identification (FRI) and any FPP. Our FRI and FPP must be reviewed and updated 
every  six  months  or  following  a  fall. Following  any  fall  we  require  72  hour  post  fall 
observations; 

b)  A “falls prompt card” for holistic assessment and to include within any FPP; 

c)  Our  homes  are  required  to  undertake  an  audit  within  48  hours  of  the  resident’s 

admission which includes a review of any mobility assessment, FRI and FPP; 

d)  We have a “falls response flowchart” which provides a clear explanation to our staff as 

to how any fall within our services should be dealt with; 

e)  A slips, trips and falls policy (last updated in May 2020); 

f)  Our  Call  Systems  and Assistive  Technology  policy  issued in December 2020  which 
introduced additional guidance regarding the use of sensor mats, the importance of 
ensuring they are placed correctly to reduce the risk of resident falls and production of 
a  new  Assistive  Technology  Sensor  Checks  form  which  is  completed  every  time 
sensors are used to ensure they are positioned and working correctly;  

g)  A detailed post-falls checklist; and  

h)  All of our staff go through a robust training programme which includes specific training 

on falls awareness.  

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 With the exception of our “Call Systems policy” all of the above falls management measures 
were in place at the care home in February 2020.  The HM Senior Coroner makes no criticism 
of the content and robust nature of these policies.  

Application of falls prevention and management procedures 

As a result of our investigation and the concerns identified once made aware of this inquest, 
we have taken a number of actions to reinforce our expectations around falls management, 
transparency and reporting. This has been communicated across all of our services.    

Specifically in relation to the management of falls risk and falls response we have: 

i) 

Introduced a detailed individual falls tracker through a falls monitoring workbook. This 
was  in  place  at  the  care  home  in  June  2020  to  enhance  falls  analysis  and  person 
centred intervention and support; 

j)  Enhanced the “Event Capture” system allowing immediate access to home level data 

across a number of categories including falls; 

k)  Reinforced the falls procedures to all staff within the care home and a undertaken a 

robust supervision (by our District Manager) on falls management to all staff; 

l)  Rolled out a series of falls awareness presentations to the care home and all homes 
across  the  district  to  ensure  that  all  staff  within  those  homes  have  a  clear 
understanding of our policies, better awareness around falls and how to manage them. 
This has been shared nationally across all of our care home services;  

m)  Held  a  series  of  management  meetings  across  the  relevant  district,  hosted  by  the 
District  Manager  and  our  client’s  safeguarding  team,  to  reinforce  the  importance  of 
accurate record keeping, reporting, transparency and openness;  

n)  Introduced  an  improved  falls  tracker  which  requires  a  physical  audit  by  the  home 
manager around the home. The District Manager has undertaken a detailed audit for 
the care home involved in the inquest; 

o)  Requested  the  District  Manager  to  review  all  falls  on  every  home  visit  to  reconcile 

recorded falls with the falls tracker and all accident and incident forms; and  

p)  Our  District  Manager  is  working  with  our  Care  Quality  Team  to  produce  a  more 
simplified version of the falls flowchart which is in the process of national rollout.   

Reporting and governance  

As  already  explained  above,  we  are  of  the  view  that  the  shortcomings  in  this  case  around 
reporting and recording were deliberate and isolated to the care home involved. They are not 
representative of how we operate across our organisation. Once identified, swift action was 
taken against those responsible. 

We have always had a strong system for monitoring and overseeing the operations of all of 
our  services  but,  as  we  are  always  seeking  to  improve,  we  have  put  in  place  additional 
supporting measures on top of those that were already there.  

We have had excellent feedback from the home managers who have been piloting the new 
falls tracker system. This initiative has been overwhelmingly positive with the tracker being a 
more  effective  means  of  overseeing  falls  management.  This  is  being  implemented  on  a 

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 national level for homes to complete on a monthly basis to ensure clearer oversight of falls 
across all services.   

In relation to the home involved, a very robust supervision around falls management has been 
given  to  all  staff  regardless  of  job  role.  This  supervision  has  been  intended  as  a  support 
mechanism for all staff in the home.  

As far as wider governance of our services is concerned, we have many processes in place 
to assist with the reporting and transparency of accidents and incidents. These include: 

q)  Quarterly reports in respect of safeguarding incidents across all care services; 

r)  Safeguarding and Serious Incident Review Board; 

s)  Internal  inspections  by  the  internal  governance  and  safeguarding  team  which  also 
provide a rating similar to that of the CQC , the inspection record is regularly reviewed 
and updated, the inspection report includes a review of a number of personal plans;  

t)  Accident  and  incident  process  flowchart  which  explains  where  and  how  incidents 
should  be  reported  through  the  Serious  Untoward  Incident  (SUI)  or  safeguarding 
procedures; 

u)  Safeguarding – Incident alert process guidance;  

v)  Safeguarding Adults at Risk Policy; 

w)  Falls  Tracker  (as  mentioned  above).  This  is  reviewed  every  month  by  the  District 
Manager  to  check  that  residents  with  high  falls  risks  have  the  appropriate 
documentation in their care plans and to check what action has been taken to try to 
reduce  further  falls  from  occurring.  This  is  included  within  monthly  reporting  of  the 
home,  prepared  by  the  District  Manager,  to  record  specific  actions  required  for 
individual residents to ensure that their falls risk is managed; 

x)  Our  Care  Quality  team  review  falls  across  the  organisation  on  a  monthly  basis  to 
identify homes and individual residents where additional support with falls prevention 
may be required from a specialist Care Quality Adviser; 

y)  Event capture system through which homes are required to electronically report any 
incidents  or  untoward  events.  This  includes  anything  relating  to  falls  and  falls 
management. All falls data input into event capture is capable of analysis at individual, 
home, district, region and national level meaning all homes can be reviewed at any 
point to provide oversight that falls are being managed appropriately.  Staff are trained 
on how to use and record incidents through event capture; and  

z)  Event capture also reports SUIs and safeguarding issues and enables each home to 
upload documents or enter additional notes. The data from the event capture system 
if fed into quarterly reports to the Safeguarding and Serious Incident Review Board.   

In addition, we have also recently introduced the following:  

aa) We have undertaken a review of our internal coroner process. This has resulted in the 
introduction  of  a  more  formal  internal  triage  arrangement  which  enables  our 
safeguarding team to monitor trends and support risk assessment; 

bb) Additional handover guidance; and  

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 cc) Improvements  to  our  Care Quality  Indicators  which provide  organisational  oversight 
across  all  of our  care  homes. This  includes  specific  incidents  including  deaths, falls 
and enables our client to address any trends or gap analysis; and monthly calls with 
the  Directors  of  Care  to  consider  risk.  Specific  recent  changes  include  the  service 
improvement  team  being  required  to  provide  reports  of  support  provided,  why  and 
where by a certain date. This means that the lead for risk consideration sits with both 
the service improvement team and Director of Care Quality which in turn will help the 
Director of Care to consider services highlighted within their region. 

We are confident that all of our processes and procedures around falls risk, risk management 
and  governance  are robust,  suitable  and  continue  to  work  well  across  all  of  our  registered 
locations.  

For and on behalf of the Anchor Hanover Group  

27 May 2021 

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