Karen Redding

STRICTLY PRIVATE AND CONFIDENTIAL 

Mr Zafar Siddique 
Senior Coroner, Black Country Area 
The Black Country Coroner's Court 
Jack Judge House 
Halesowen Street 
West Midlands  
B69 2AJ 

Dear Mr Siddique 

14 January 2022 

Report for the Prevention of Future Deaths following Inquest into the death of Ms Redding 

I  am  writing  to  you  on  the  behalf  of  Cherish  Homecare  Limited  (“Cherish”)  further  to  the 
Inquest into the death of Karen Redding and the Report for the Prevention of Future Deaths 
dated 18 November 2021.  

Cherish Homecare Limited 

Cherish was established as a homecare agency in 2002 and since this point, we have been 
providing  care  and  support  to  a  wide-range  individuals,  with  a  wide  range  of  needs,  within 
their  own homes and  in the  broader  community. The  care  we  provide to service  users  can 
range from a few hours a week to live in care provided on a 24-hour basis. 

We support older people and younger adults, with ranging levels of need. The type of care 
provided can include personal care (such as support with washing, bathing, and showering, 
continence care and assistance with dressing), nutritional care (including the preparation of 
drinks, light meals, breakfast, hot meals/ snacks and managing food hygiene) and practical 
support (including making/changing the bed, laundry/ironing,  shopping, and light household 
duties).  We  are  also  able  to  provide  sit-in  care  (more  closely  monitored  day  and/or  night 
support for those living alone), live in care (where a carer lives in a service user’s home and 
provides  care  on  a  long-  or  short-term  basis  allowing  a  more  acute  care  service  to  be 
delivered)  and  reablement  support  (care  following  discharge  from  hospital,  recovering  from 
accidents or recovery for the effects of an illness etc). 

At Cherish, we take the view that all the individuals we support, deserve a high quality and 
personalised  service,  which  is  regular  and  on  time,  every  time.  We  believe  in  self-directed 
support  and that  everyone  should  have  choices  and  control  over  their  own  lives  and  to  be 
able  to  make  decisions  about  their  chosen  lifestyle.  We  value  the  care  and  support  each 
individual  receives  from  their  relatives  or  others  close  to  them  and  aim  to  work  alongside 
them and include them in the service we provide to their loved one.  

Our  key  objective  is  to  ensure that the  independence,  privacy,  and dignity  of  all  individuals 
we support, is maximised to the full through comprehensive, high quality personalised care, 
delivered to meet their specific individual needs and choices. 

 
 Ms Karen Redding  

In  the  first  instance,  I  wanted  to  take  the  opportunity  to  confirm  some  points  regarding  the 
care delivered to Ms Redding. Cherish provided care to Ms Redding from 9 November 2020 
to 24 March 2021. Ms Redding lived with her partner – 
 - who was her main carer and 
next of kin that supported Ms Redding in any decision making. Ms Redding was 60 years of 
age and had full mental capacity and acumen to make her own decisions. Since the start of 
Ms Redding’s package of care, Cherish was not involved in Ms Redding’s medication and all 
medication needs were managed and coordinated by Ms Redding herself and 

.  

Actions taken following the death of Ms Redding 

On the carer’s arrival on 25 March 2021 to deliver the morning call, they were informed by a 
police  officer  that  Ms  Redding  had  passed  away  that  morning;  at  this  stage,  the  cause  of 
death  was  unknown.  Notwithstanding  this,  an  internal  investigation  was  immediately 
commenced  to  consider  the  circumstances  on  24  March  2021  and  what  lessons  could  be 
learnt to prevent similar circumstances arising in the future. As part of this investigation, the 
following steps were taken.  

•  On 25 March 2021 all records on the system were examined and an emergency 

office staff meeting was undertaken. During this meeting, we introduced the following 
procedure for where a medication overdose or a similar incident where the service 
user requires medical assistance, occurs – 

•  Regardless of what service users, family members or any other next of kin 

may want, staff must take the initiative to seek medical help and support i.e., 
contacting the GP, Pharmacist, NHS 111 or 999. 

•  Though service users or family members can be awkward in such situations, 
we should not be concerned of potential risk of complaints due to overriding 
their decisions and instead we should call for the appropriate medical 
assistance.1 

•  Also on that day, all care staff involved in Ms Redding’s care on 24 March 2021 were 

contacted and they were requested to attend a meeting on 26 March 2021.  
•  On 26 March 2021, a meeting was conducted with all care staff who attended Ms 

Redding’s calls at lunch, tea, and bedtime on 24 March 2021. We also met with these 
care staff individually and obtained statements. 

Evidence collated suggests that the office was made aware by the visiting care staff that Ms 
Redding had consumed more oral medication than the recommended dosage. This 
information was confirmed by Ms Redding and her partner. Office staff advised 
take the appropriate action of contacting the GP or 999 for an ambulance, and in turn, 

 to 

 assured the office staff and care staff, on more than one occasion, that he would if 

required. Evidence of feedback collected from the office staff also indicates that if the office 
staff members on duty had somewhat of an inkling that 
 would not follow the advice 
given to him by the office and care staff members, then carers would have been instructed to 
call out for paramedics themselves.   

1 We would also notify / report to the Care Quality Commission and local authority safeguarding team 
as appropriate.  

 
 
 
 
 
 
 
 As an organisation, Cherish is committed to continuous learning and driving improvement. 
We recognise the opportunity of learning lessons from such incidents and improving our 
practices at an individual level as well as at an organisational level. 

In the 19 years of Cherish providing care, no incident of this type has ever occurred. 
Management has reviewed the effectiveness of medication policies, procedures and working 
practices to ensure such circumstances are not repeated.  

The following measures have been implemented as a preventive means to ensure such 
circumstances do not arise again in the future.  

1)  The medication policy, procedures and practices were reviewed and revised 

accordingly. The procedure discussed above for medication overdoses or similar 
incidents where the service user requires medical assistance was implemented 
immediately.  

2)  All office staff were made aware of the procedure for seeking medical assistance 

discussed above, through staff meetings. 

3)  Shortly after the incident, all care staff involved received refresher training in 

medication including the significance of calling for paramedics regardless of notions 
displayed by service users and/or their next of kin. All other care staff were contacted 
via text message and notified of the procedure for seeking medical assistance.  
4)  A medication overdose policy was introduced. It should be noted that this policy 

confirms the procedure discussed above and states the following: “Remember to 
contact the office asap to inform them of the situation at hand. Office staff to 
call 999 or NHS 111 regardless of whether the service user or their Next of Kin 
agrees or not”. 

5)  Medication refresher training was delivered to all care staff members in the company 

in July, August, and September 2021. 

6)  New staff will be introduced to the medication overdose policy and the procedures for 

seeking medical assistance through their induction process.  

We noted your comments in the Report that our management team may wish to consider 
reviewing the training and guidance to care staff relating to handing items to service users 
and checking the contents of boxes. With consideration of the circumstances surrounding Ms 
Redding’s death, we have, as directed, reflected, and reviewed on Cherish’s approach to this 
issue and the training and guidance provided to staff. We have concluded that the general 
approach we currently adopt and instruct care workers to take remains appropriate.   

It is very typical for carers to ask a service user before they leave the call if they can assist 
them any further; this may be through handing items to them. Whilst circumstances should 
be considered on a case-by-case basis, as a general approach, where a service user has full 
capacity and asks a carer to hand something to them, we would expect a carer to hand that 
item to them, without further questions or for example checking the contents of the bag, box 
etc. It is paramount that carers and Cherish respect people’s privacy and promote their 
independence; it is not for our carers to unreasonably control what people with capacity to 
make their own decisions can and cannot do or to “police” their lives. In this instance, Ms 

 
 
 
 
 
 
 
 Redding controlled her own medication and had mental capacity to do so; Cherish was not 
commissioned to provide support with medication and so it was expected and typical that Ms 
Redding would handle her own medication.  

We would, however, expect a carer to ask questions or check the contents of bags, boxes 
etc in a respectful and appropriate manner if they were asked to hand an item to a service 
user and they had specific concerns about doing so (so for example, if the service user 
lacked mental capacity, was presenting as confused or expressed suicidal ideations). If 
carers had any concerns regarding what they were being asked to do following questions or 
checking, we would expect them to call the office. Where carers have a concern of the type 
mentioned, it is highly likely that they would call the office anyway (regardless of whether 
they were asked to hand over an item) to report and seek guidance as to appropriate actions 
/ next steps. This would be in line with the training they receive. Such a concern did not arise 
on the day in question in relation to handing the box to Ms Redding and so we would not 
have expected the carers to have refused to hand it to her.  

In addition to the above, the following measures are in place to ensure service users 
continue to receive safe and effective care. Cherish conduct monthly audits of the daily 
records and MAR charts for each service user. We audit a sample of the daily records and 
charts for each service user from a few days of each week. This audit is conducted by our 
specific member of office staff with responsibility for quality assurance.  

If any concerns are raised through the audit these will be investigated. The nature of the 
investigation undertaken will depend on the circumstances, but generally where a concern 
regarding reporting and recording by a carer arises, we will ring that carer and speak to them 
about it. We will also follow this up by sending them a message reiterating the importance of 
logging and reporting correctly. Every 3 months we review the results of the audits to identify 
any patterns or trends and we will respond to any identified patterns / trends accordingly.  

We also conduct monthly courtesy calls with service users to assess whether they are happy 
with the care being provided to them. There are a number of set questions that we ask. The 
calls may give rise to the need for action and this need will be recorded, as will the action 
taken. Often during these courtesy calls, service users will praise staff and these 
compliments will be passed on. We analyse the results from the courtesy calls on a quarterly 
basis to identify any patterns or trends and we will respond to any identified patterns and 
trends accordingly. 

Specifically in relation to medication, we would note that almost all of the calls Cherish 
deliver are double up calls and during these double up calls, carers are required to work 
together when administering medication to ensure it is done correctly. For example, one 
carer will check the other has selected the right medication, dosage etc. One carer will 
usually complete the daily records but the second is required to record and sign to verify the 
actions taken, including where applicable, that the medication was administered correctly. If 
during the audit we identify the second carer has not written in the daily records as 
described, this will be picked up and actioned with the relevant carer.  

 
 
 
 
 
 
 
 
 Medication is typically discussed during supervisions with carers (alongside the importance 
of recording). We also conduct spot checks with carers every 3 months which will cover 
medication. We used to conduct these spot checks on an annual basis, however we took the 
decision to increase the checks to every 3 months from September / October 2021 to 
respond to feedback from staff as to what would be helpful.  

I would like to take this opportunity to express my sincere condolences to Ms Redding’s 
family and friends. She was well regarded by those who cared for her and will be missed.  

Please do not hesitate to contact me should you have any questions.  

Yours Sincerely  

Managing Director  
Cherish Home Care Ltd