Bridget Gormley

30 March 2023 

David Donald William Reid  

HM Senior Coroner for Worcestershire   

Coroners Court 

Martins Way 

Stourport on Severn 

Worcestershire 

DY13 8UN 

Dear Mr Reid  

Regulation 28: Report to prevent future deaths in relation to Bridget Gormley 

I am responding to the Regulation 28 Report issued on 9 February 2023 following the inquest into the 

death of Bridget Gormley on 31 July 2022. The inquest concluded on 8 February 2023.  

Barchester Healthcare (‘Barchester’) deeply regrets the death of Mrs Bridget Gormley and the distress 

this has caused her family.    

Following this very sad incident we have made a number of changes to the provision of care and services 

at Latimer Court, and these have been adopted across the organisation in other services and divisions 

where appropriate.  For the purpose of this response, we have considered the concerns raised by you 

and where possible we have grouped together details of assurance measures where these appear to deal 

with more than one area of concern. Whilst it is unlikely that the matters referred to below would have 

affected  the  outcome  for  Mrs  Gormley,  there  are  matters  of  practice  identified  where  the  need  for 

improvement has been recognised and dealt with.    

(1) 

During the course of her evidence, the inquest heard that Mrs. Gormley had suffered four falls 

at Latimer Court between 31 March 2022 and 4 April 2022, and a further four falls between 12 

July 2022 and 17 July 2022. Latimer Court’s registered home manager, 

, conceded 

in her evidence that neither Mrs. Gormley’s Falls Risk Assessment document, nor her Falls Care 

plan document were updated following any of these falls, and that they should have been so 

updated. This meant that:  

(a)  Staff at Latimer Court who were looking after Mrs. Gormley may not have been aware that 

she presented an increased risk of suffering a fall; and  

(b)   Measures to mitigate that increased risk were not considered. Such measures could have 

included: 

(i) 

Asking a GP to refer Mrs. Gormley to the falls clinic. 

(ii) 

Placing a sensor mat by her bed or chair, to alert staff to when she was mobilising.  

 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 (iii) 

Referring her to Occupational Therapy for mobility aids such as a walking stick or 

frame. 

(iv) 

Briefing  staff  at  Latimer  Court  to  intervene  whenever  Mrs.  Gormley  was  seen 

mobilising by herself, and to offer her assistance.  

(2) 

 was unable to explain why these important documents had not been updated as 

they should have been by staff at Latimer Court. There is therefore concern that staff at Latimer 

Court did not, and may still not understand their duties and responsibilities to update residents’ 

documentation in such circumstances 

I have addressed the concerns below: 

Falls Management  

(a)  At  Barchester  Healthcare,  all  residents  care  plans  are  reviewed  by  the  senior  carer  in  a 

residential home every month or when anything significant changes in their care or support 

requirements such as a fall. This process is then audited and assured by the unit General 

Manager via the resident of the day process of checking up on care planning. Care plans 

may also be updated following the daily clinical meeting led by the care home clinical lead 

which is often the Deputy Manager. At this meeting residents who may have fallen, been 

unwell or been to hospital are discussed in more detail. All incident forms from the previous 

24  hours  are noted  as  incidents  for  review  and  prompt  the  General Manager  to cascade 

relevant information and support to the home team. Appropriate actions will be discussed 

and  documented  including  the  need  to  make  staff  aware  of  any  increased  risk  to  the 

resident  and  extra  vigilance  and/or  assistance  as  necessary.    Both  processes  are 

documented  daily,  and  records  kept  which  are  themselves  reviewed  by  the  Regional 

Director  and  the  Quality  Assurance  Team.   As  part  of the  processes  there  is  a  record  of 

discussions and where appropriate a record of any request submitted to the commissioners 

of care i.e., Local Authority, Clinical Commissioning Group, Integrated Care Board and/or 

Next of Kin and evidence of the outcome of those discussions. Referrals to GP, Falls Team 

and  Occupational  Therapist  are  considered.   There  is also  reflection  on  duty  of  candour 

obligations and reporting to family, CQC and Safeguarding Vulnerable Adults. As part of 

the resident of the day process there will be a review of medication and a formal request 

for a GP review of medication evidenced where it is considered that medication may be a 

contributing factor to falls.   

(b)  Care  Plan reviews  also  take  place  6  weeks  following  admission  and every  6  months;  the 

care  review  process  involves  the  resident  and,  where  they  lack  capacity,  their  family. 

Checking  these  documents  forms  part  of  the  Regional  Director  monthly  home  visit  and 

Barchester’s  Quality  Improvement  Team  carry  out  audit  to  make  sure  that  this  is  being 

done.   

(c)  Following any fall or found on floor incident the falls risk assessment should be reviewed 

and  the  falls  diary  completed.    The  falls  care  plan  should  be  updated  accordingly  and 

referrals made as appropriate. 

(d)  The  incidents  involving  Mrs  Gormley  had  been  captured  on  the  accident  and  incident 

reports, but the care plan review process had not apparently picked up the need to review 

and where necessary update the falls documentation. Incident reporting is required to be 

 
 
 
 
 
 entered  onto  the  clinical  governance  system  within  24  hours.  To  address  this,  we  have 

amended our monthly clinical governance meeting requirements to include a review of falls 

for  any  one  individual  and  their  falls  history.  These  meetings  are  minuted  and  require 

discussion  of  residents having  a  fall  or  found  on  the  floor  in  line with  Barchester’s  Falls 

Management Policy to ensure that all measures are in place to mitigate the risk of further 

falls and that the relevant Healthcare Professionals and equipment is accessed and utilised.  

We have also introduced a regional falls champion forum, chaired by our Divisional clinical 

lead  nurses.  This  will  have  an  emphasis  on  prevention  but  also  include  reviews  of 

individuals who have fallen, and the documentation required to support them and plan for 

their needs.  

(e)  Barchester’s  Director  of  Nursing  has  undertaken  a  review  of  policies,  processes  and 

procedures in relation to falls and falls management. The Barchester Healthcare policy for 

Falls Management has been subsequently updated and this update has been shared by the 

General Manager of Latimer Court with the home team, specifically the senior carer team 

whose responsibility it is to manage falls. 

(f)  Barchester  Healthcare  have  also  now  developed  and  introduced  a  specific  Post  Falls 

Assessment Tool to aid with the assessment of a resident following a fall or found on floor 

incident. This assessment process explores pain, any bruising or wounds and any changes 

in limb movement or walking. It also makes clear the process and frequency of observations 

and escalation should there be a change from a resident’s baseline. 

(g)  Appendix 3 of the Barchester Falls Management Policy sets out a flow chart for immediate 

action following a fall or finding someone on the floor. This appendix is displayed in the 

care stations in the home for ease of reference for the senior care team and is intended to 

seek to ensure that due process is followed in each case. 

(h)  Barchester Healthcare have worked with RoSPA in the Falls Fighter campaign with the aim 

to  raise  awareness  of  falls.  This  has  involved  training  across  Barchester’s  homes  and 

cascading to team members and will continue as part of the ‘Falls Fighters’ campaign.  Falls 

Fighters attend the monthly Clinical Governance meetings.  

(i)  As an organisation we take our responsibilities and the duties and responsibilities of our 

staff  very  seriously.  Robust  documentation  is  an  important  tool  in  care  planning  and 

communication.    We  do  not  assume  that  all  staff  approach  the  completion  of 

documentation  as  mandated  by  the  organisation in  a comprehensive  and  timely manner 

although  that  is  our  expectation.  We  recognise  that  reinforcing  the  importance  of  good 

documentation and the processes that will flow from that is a key foundation stone in our 

approach to mitigating risk for our residents and person-centred care planning.  

Latimer Court  

(j)  As part of the lessons learnt as identified by the General Manager at Latimer Court it was 

highlighted  that  staff  required  further  training  from  the  organisation’s  Clinical 

Development  Nurse  in  the  approach  to  and  completion  of  documentation.  Specifically, 

when to complete documentation and the requisite detail to be included in the entries into 

documentation.    Following  completion  of  the  inquest  and  receipt  of  the  Regulation  28 

Report, the Managing and Regional Directors have made arrangements for further refresher 

training to be delivered at Latimer Court with follow up by the Regional Manager and Quality 

 
 
 Assurance Team. This will take place over the next 6 weeks and will be repeated at intervals 

as necessary. As part of the training delivered, the specific concerns arising out of this case 

will be used as a case study to demonstrate how the updating of documentation may lead 

to  measures  to  mitigate  increased  risk.  There  will  be  an  additional  emphasis  on  the 

requirement to maintain robust handover documentation on a daily and weekly basis.  

(k)  As part of lessons learnt it is recognised by the General Manager at Latimer Court that staff 

require further training on the Barchester Falls Management Policy. If staff had followed the 

policy in this case, they would have followed the prompts to ensure that every aspect of 

the risk review was undertaken along with the immediate action following a fall or found 

on  the  floor  incident.  This  includes  consideration  of  the  environmental  orientation  tool 

which should be completed preadmission and on admission and revisited following a fall. 

The  Managing  and  Regional  Directors  have  therefore  made  arrangements  for  further 

refresher training to be delivered at Latimer Court with follow up by the Regional Director 

and Quality Assurance Team. This will take place with the documentation training over the 

next 6 weeks and will be repeated as necessary.  Any checklists or prompts to be used at 

Latimer Court by the home team will be developed in liaison with the Clinical Development 

Nurse and will follow the requirements of the Falls Management Policy as to actions to be 

taken. As part of the training staff will be required to review the environment in which the 

residents live, practice writing risk assessments and consider how residents needs and risks 

may change and to develop professional curiosity about residents’ presentation and  any 

referrals and actions that should flow from a falls incident. 

(l)  The training referred to will be attended by all staff at Latimer Court including the General 

Manager.   

(m)  Finally, the General Manager at Latimer Court is being provided with increased support by 

the Managing and Regional Directors and the Clinical Development Nurse whilst the further 

refresher training is embedded, and a permanent Deputy Manager has been recruited to 

support the General Manager and the team at Latimer Court going forward.   

Thank you for raising your concerns. I hope that the content of this letter provides sufficient assurance 

that Barchester Healthcare take the concerns raised seriously, has taken action following the death of 

Mrs Bridget Gormley and has accepted the points raised and continues to work to improve the service 

we provide. Should you have any questions or concerns or comments, please do not hesitate to contact 

me directly. 

Yours sincerely 

Chief Executive Officer  

Barchester Healthcare