Lugh Baker

DWF Law LLP 
Redcliff Quay  120 Redcliff Street  Bristol  BS1 6HU DX 7841 Bristol 
T +44 (0)333 320 2220  F +44 (0)333 320 4440  dwfgroup.com 

Mr Cox, HM Senior Coroner 
Coroner for Cornwall and the Isles of Scilly 
HM Coroner's Office 
Pydar House 
Pydar Street 
Truro 
Cornwall 
TR1 1XU 

Date: 

9 May 2023 

Dear Sir 

Inquest: 
Lugh Baker (Deceased) 
Our Client:  Bowden Derra Park Ltd 
Matter: 

Regulation 28, Report to Prevent Future Deaths 

We are writing further to the Report to Prevent Future Deaths, received on 14 March 2023. We write 
on behalf of our client to provide the documentation requested by you in that report. 

Section 5 of the Report to Prevent Future Deaths states as follows: 

The MATTERS OF CONCERN are as follows. – 

i. 

ii. 

iii. 

I  heard  evidence  at  inquest  that  all  residents  were  constantly  monitored  yet  I  found  as  fact  that 
there were times when this did not happen for Lugh. I was informed that a new system has been 
put  in  place  requiring  staff  to  sign  a  form  indicating  the  periods  in  time  when  they  were 
responsible for monitoring residents. I asked for evidence to demonstrate this (a completed form) 
and for confirmation that, where there were any gaps in monitoring, these were explained on the 
form. 

Concern was raised that Care Plans for new residents were not reviewed sufficiently  promptly. I 
asked to see a policy  document setting  out  the expectation  for healthcare professionals  for how 
long it should take for a new resident’s Care Plan to be reviewed after admission. 

Concern was also raised about what steps will be taken, and when, where a new resident with an 
unusual  presentation  is  admitted.  In  this  case,  Lugh  had  a  diagnosis  of  Angelman’s  syndrome 
with which staff were unfamiliar. Again, I asked to see a policy document setting out what training 
or other steps will now be taken in such circumstances and by when. 

In response to the above, we enclose the following: 

1.  Nocturnal CCTV Monitoring Chart 

This  is  a  completed  Nocturnal  CCTV  Monitoring  Chart  dated  24  January  2023  until  28  January 
2023. 

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 2.  Updated Nocturnal CCTV Monitoring Chart 

The  Nocturnal  CCTV  Monitoring  Chart  has  been  updated  since  the  Inquest  and  now  includes  a 
'comments'  box  and  instructions  to  detail  any  gaps  in  monitoring  in  this  box.  Gaps  in  monitoring 
should only happen in exceptional circumstances, such as an emergency. 

3.  Care Plan Policy 

The  Care  Plan  Policy  has  been  updated  since  the  Inquest.  For  ease  of  reference,  the  updated 
sections are highlighted. The care staff have access to all policies and procedures on an application 
called BrightHR. All care staff receive training on this application and this specific policy during their 
two  week  induction  programme.  When  any  policy  or  procedure  is  updated,  the  care  staff  are 
notified  automatically via  the  application.  Once  notified, all  care  staff  must  acknowledge  receipt of 
the  notification  and  open  the  document  to  confirm  that  they  have  read  it.  The  BrightHR  system 
tracks this and alerts management of any non-compliance. 

4.  Training Policy 

As  above,  The  Training  Policy  has  been  updated  since  the  Inquest.  For  ease  of  reference,  the 
updated sections are  highlighted. The care staff have  access to all policies and procedures on an 
application called BrightHR. All care staff receive training on this application and this specific policy 
during  their  two  week  induction  programme.  When  any  policy  or  procedure  is  updated,  the  care 
staff  are  notified  automatically  via  the  application.  Once  notified,  all  care  staff  must  acknowledge 
receipt of the notification and open the document to confirm that they have read  it.  The BrightHR 
system tracks this and alerts management of any non-compliance. 

This response contains reference to and copies of internal documents, which were requested in the 
Report  to  Prevent  Future  Deaths.  It  is  respectfully  submitted  that  for  this  reason  it  would  be 
inappropriate to publish the response and/or enclosures. 

Please do not hesitate to contact us should you require anything further from our client. 

Yours faithfully 

DWF Law LLP 

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