Julie Nolan

Mr Andrew Hetherington 
HM Senior Coroner for North Northumberland and Acting Senior 
Coroner for South Northumberland  
County Hall 
Morpeth 
Northumberland  
NE61 2EF 

Dear Sir, 

Inquest into the death of Julie Nolan 

We write to formally respond to your Prevention of Future Deaths (PFD) Report, dated 11 May 2023, 
received  on  25  May  2023  following  the  sad  death  of  Mrs  Julie  Nolan.    As  an  organisation,  we  are 
ensuring that we learn from the circumstances of Mrs Nolan's death and that appropriate action is taken 
so that a death does not occur in similar circumstances.   

We  have  reviewed  the  concerns  identified  in  your  PFD  report  and  we  shall  respond  to  each  of  your 
concerns in turn:  

Concern 1: The deceased was a resident at Astor Lodge Care Home. I am concerned there was limited 
documentation of wound management and pressure care and it is unclear the extent to which wound 
management and repositioning was provided in line with care plans.  

We accept that regretfully we were unable to provide sufficient documentation at the inquest, for which 
we apologise, this was a consequence of the Home being unable to locate a full set of records for Ms 
Nolan.    Unfortunately  the  record  keeping  in  respect  of  the  care  provided  to  Ms  Nolan  fell  below  the 
standards we expect across the organisation.  We were able to confirm at the inquest, that on the basis 
of the documentation that had been located, there was evidence of a detailed care plan in relation to 
Mrs Nolan's wound management and pressure care, however , the Home was unable to provide records 
to  evidence  the  implementation  of  these  care  plans.  Evidence  was  however  provided  by  a  Care 
Practitioner, who was able to confirm that positional changes and wound management did take place.  

 (Group Complaints and Compliance Manager) was able to provide 
At the inquest, 
details of the prompt and comprehensive actions which were taken by the company and within the Astor 
Lodge, once the issue of the missing records was identified. They are summarised below: 

1. 

Senior  members  of  the  Regional  Management  team  are  currently  overseeing  operations  at 
Astor Lodge, pending the  commencement  of our new permanent  Care Home  Manager (July 
2023).  The Senior Management team are currently conducting an audit of every resident file to 

Registered Office: 
Maria Mallaband Care Group 
Westcourt, Gelderd Road. Leeds.  LS12 6DB 
Tel. 0113 238 2690  Fax: 0113 238 2691 
Email: admin@mmcg.co.uk 
www.maria-mallaband.co.uk 
Company Number: 03135910 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2. 

3. 

4. 

5. 

6. 

7. 

8. 

ensure that every resident has relevant and appropriate care plans in place, that these plans 
are being followed and that there is documentary evidence confirming the same. This includes, 
but is not limited to, care plans for wound management and pressure care.  

All of the Care Homes across the company are being transitioned to fully electronic records.  All 
Homes are now fully electronic, in relation to medication systems, and we are currently working 
on transferring all care planning over to the electronic system. In preparation for that transition, 
the records at Astor Lodge and other Care Homes, where records are currently paper based, 
are being reformatted to ensure that the paper records mirror the required electronic format and 
more person centred content of the records held on the electronic system.  

As  part  of  the  change  in  documentation,  skin  integrity  plans  for  residents  who  have 
wound/pressure  damage  have  been  updated,  ensuring  person  centred  care  and  a  clear 
pathway for any required escalation checks are carried out to ensure that, when required, there 
is timely and appropriate liaison with Tissue Viability Nurses as per company policy.  Wounds 
are also being photographed, as prescribed within the relevant care plan to ensure any wounds 
are monitored, changes identified and care plans and treatment adjusted accordingly. 

Every  member  of  staff  is  required  to  undertake  mandatory  training  when  they  commence 
employment at Astor Lodge, and currently a full refresh of training is taking place. This training 
incorporates training on wound care and pressure damage and this training is repeated on an 
annual basis. Checks have been carried out to ensure that appropriate staff within the Home 
are compliant with their mandatory training to ensure that they have received the most  up to 
date annual wound care and pressure area care training. 

Following Mrs Nolan’s death, a clinician from the Quality Support Team has been working with 
staff  from  Astor  Lodge,  with  care  plan  and  risk  assessment  training,  looking  specifically  at 
lessons learned from the clinical issues which arose in Mrs Nolan's case. This training includes, 
but  is  not  limited  to,  a  discussion  around  the  importance  of  documentation,  evidencing 
improvements in the safe care and treatment of individuals, how we make referrals to outside 
healthcare professionals and how we carry out and evidence any action or treatment advised 
by our community partners. 

The training reinforces the need for staff to maintain accurate, complete, and detailed records 
in  respect  of  each  resident,  with  any  care  or  clinical  interventions  and  daily  records,  being 
completed throughout the whole of a shift, to reflect each intervention any resident may receive 
and to ensure that records are current, reflective and completed in a timely manner.  

Relevant senior staff  are also attending RESTORE2 on an ongoing basis (an escalation tool 
used in care setting to enable early recognition of deterioration) training, which is delivered by 
inhouse  trainers  through  our  Learning  and  Development  team  and  is  available  on  a  rolling 
monthly basis for staff to book onto. This training  includes  guidance on acute infections and 
how  to  identify  signs  and  symptoms  of  them,  understanding  the  potential  risks  of  sepsis, 
including  signs  and  symptoms,  and  when  to  seek  further  advice.  Within  this  training,  the 
importance  of  baseline  observations  and  the  use  of  the  SBAR  (Situation,  Background, 
Assessment  and  Recommendation)  tool  is  also  discussed.  Any  additional  training  needs 
identified, will be delivered by our Learning and Development team as required.  

Senior staff are also receiving react to red training booklet, which includes refresher training on 
the normal structure and functions of the skin, how pressure ulcers develop, the importance of 
risk  assessments,  skin 
the 
management of existing pressure damage and encouraging personal engagement. This booklet 

inspection,  pressure  ulcer  prevention,  repositioning  and 

Page 2 of 4 

 
 
 
 
 
 
 
 
 
 
 
 9. 

10. 

11. 

12. 

13. 

14. 

requires the staff to work through the training materials and then answer questions, at the end 
to  test  their  knowledge  and  understanding,  and  progress  being  monitored  by  the  Senior 
members of the Regional Management team .  

In order to ensure that documentation is being completed correctly, the Senior members of the 
Regional Management team are responsible for carrying out daily walk arounds, which includes 
walking  around the Home  and  focusing on key areas of risk and  addressing areas that  may 
require  further  input,  such  as  the  home  environment  and  any  issues  arising  around  resident 
care, documentation, staff and COVID 19 compliance. This process was in place at the time 
Mrs Nolan was a resident, but was not always completed as robustly as we would expect. 

To ensure that this is being undertaken and to assist with the recording of this process, the walk 
around form has been made electronic and updated to set out each action the manager needs 
to  complete  during  the  walk  around,  with  the  requirement  to  upload  picture  evidence  of  any 
findings.  These walk arounds are now audited as a minimum every week by the Quality Teams, 
with  the  results  uploaded  and  available  to  be  reviewed  by  Regional  Director  and  Quality 
Excellence Team and action plans are created to address any issues identified.  

In  addition  to  the  walk  around,  Senior  members  of  the  Regional  Management  team  are 
introducing audits of 10% of care plans within the Home on a monthly basis, to ensure that all 
documentation and care plans are in place and are in line with company policy. Audits are also 
being  monitored  on  a  monthly  basis,  through  Regional  Director  visits,  which  encompass 
completion  of  an  electronic  document  (Regional  Director  Visit  Report)  to  review  what  audits 
have been undertaken. This report is also currently being updated to be more prescriptive about 
the checks required, and include a reference to checking walk arounds and all relevant audits 
have been undertaken.  

Any  residents  identified  at  risk  of  pressure  damage  or  other  factors  such  as  falling  are  also 
reviewed  on  a  weekly  basis  by  the  clinical  team  to  ensure  that  the  Senior  members  of  the 
Regional Management team and staff have full oversight and awareness of any residents that 
they deem at risk. This  ensures areas of focus, such as time pressure damage, serious changes 
in  health  status  and  infections,  are  reviewed,  by  the  Senior  members  of  the  Regional 
Management team , Quality Excellence Partner and Regional Director, requiring sign off on a 
weekly basis by the Home manager and on a monthly basis by the Regional Director.  

Since Mrs Nolan’s death the format of this document has changed to be more prescriptive and 
will  be  converted  into  an  electronic  form  as  part  of  the  move  to  fully  electronic  records.  The 
Senior members of the Regional Management team are ensuring compliance with this process 
and  completion  of  this  document  is  also  now  checked  and  recorded  as  part  of  the  monthly 
Regional Director visits.  

In addition to the internal quality assurance checks conducted within Astor Lodge as referred to 
above, the company’s Quality Excellence Team will be conducting random 'spot checks' at the 
Care Home, on a regular basis.  These checks will include ensuring documentation is completed 
to the required standard, as set out in relevant policy and training. If any issues are identified, 
as part of the spot checks, an action plan will be prepared to address these, and specific staff 
will be allocated the action to complete. This is then monitored locally and regionally in respect 
of action compliance via our quality management system. 

15. 

There is no evidence that Mrs Nolan’s care records were selected as part of this higher level 
audit, however there is no indication that during Mrs Nolan’s stay there were concerns identified 
with care plans and records not being completed at Astor Lodge..  

Page 3 of 4 

 
 
 
 
 
 
 
 
 
 
 
 16. 

17. 

18. 

In terms of the storage of records, we are introducing that each resident’s records are signed 
off  at  the  end  of  each  shift  by  the  nurse  in  charge  and  placed  into  the  relevant  box  for  that 
resident, with a list made of what is contained in each box. Unfortunately, at the time of Mrs 
Nolan’s residency it has come to light that this process for the storage of records was not being 
followed consistently. The  Senior members of the Regional Management team, are currently 
overseeing  the  archiving  process  to  ensure  that  this  is  being  followed  correctly  and  all 
documents are  being  organised  and filed into allocated boxes that  are trackable and  can be 
located via our internal archiving system.  

In addition the company’s Data Protection Officer and Head of Information Governance have 
been  made  aware  of  the  past  storage  issues  for  future  monitoring.  A  number  of  checks  of 
services focusing on data storage will occur and heightened awareness sessions are in place 
to  ensure  consistent  updates  and  reminders  to  services  on  the  importance  of  appropriate 
document storage and archiving.  

Since the conclusion of the inquest, a National Webinar has taken place (19 May 2023) attended 
by all care homes within the organisation, regional quality and director teams along with legal 
representatives,  which  discussed  the  findings  at  the  inquest  and  amongst  other  matters,  the 
importance of wound and pressure management. In addition, the need to accurately document 
any  care  and  treatment  required  was  reinforced  to  staff  as  well  as  a  reminder  to  ensure 
appropriate storage of documentation and the need to consider escalation to Tissue Viability in 
a timely way and monitor any deterioration and take photographs of wounds. These webinars 
have been scheduled on an ongoing basis for a variety of topics. 

Concern 2: I am concerned that the Manager and Registered Nurse was the designated nurse for the 
Care Home for two consecutive days.   

As confirmed in the inquest, at the time of Mrs Nolan's death there was a significant COVID outbreak 
within the Home.  Staffing pressures due to COVID meant that unusually the manager was allocated 
nursing shifts in order to ensure that the Home was operating at a safe level. Whilst the manager was 
named  as  the  nurse  for  two  consecutive  days,  this  did  not  mean  that  she  was  constantly  working 
throughout this period and instead the requirement was for her to sleep on site, only to be contacted by 
staff in an emergency. 

In this response we have outlined the actions we have already taken, and those which we  are in the 
process of taking.  In providing this response to you, we hope that we have conveyed how seriously we 
have viewed this matter and that we are committed to learning from Mrs Nolan's death.  

We trust that this response has answered your concerns, but please do contact me should you have 
any queries or concerns. 

Yours faithfully 

Chief Executive Officer 

Page 4 of 4