Anthony Friend

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1) 

, Director, Bluebird Care, 3 Millenium Court, Buntsford Park 

Road, Bromsgrove, Worcestershire B60 3DX 

1  CORONER 

I am David Donald William REID, HM Senior Coroner for Worcestershire. 

2  CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 
2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 

3 

INVESTIGATION and INQUEST 

On 25 April 2023 I commenced an investigation and opened an inquest into the death 
of Anthony John Friend. The investigation concluded at the end of the inquest on 5 
September 2023. 

The conclusion of the inquest was that Mr. Friend died as the result of an accident. 

4  CIRCUMSTANCES OF THE DEATH 

In answer to the questions “when, where and how did Mr. Friend come by his death?”, 
I recorded as follows: 

“On 17.4.23 Anthony Friend, who was living with the effects of a brain tumour and 
required regular personal care visits at his home in Bromsgrove, sustained a 
significant head injury after slipping through a sling while being hoisted from a chair to 
his bed, and striking his head on the frame of the hoist. He was discharged from 
hospital back home for palliative care, and declined and died there on 20.4.23. The 
sling being used at the time of the fall had previously been adjudged unsuitable for his 
care needs, but it was not removed from his property, and no instruction had been 
given that its use should cease.” 

5  CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern. 
In my opinion there is a risk that future deaths will occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.  – 

In the course of the inquest, I heard evidence that: 

1)  Bluebird Care provided care at home for Mr. Friend up to 16.4.23 ( two days 

2) 

before the accident which led to Mr. Friend’s death ); 
the reason Bluebird Care stopped providing care for Mr. Friend was that they 
had concerns about the sling which was still being used with his hoist; 
3)  Bluebird Care knew by 12.4.23 that Mr. Friend’s care at home after 16.4.23 

would be provided by Divine Health Services Ltd.; 

4)  At no time did Bluebird Care try to make contact with, or provide any sort of 
handover to Divine Health Services Ltd. about Mr. Friend’s needs, or about 
any concerns they had concerning the sling. In her evidence to the inquest, 

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 , Bluebird Care’s registered care manager, agreed that it was 

“common sense…for there to be a good handover between care agencies”, 
but that it “was not something which we had ever done”. 

6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you, as 
the Director of Bluebird Care, have the power to take such action. 

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 13 November. I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting 
out the timetable for action. Otherwise you must explain why no action is proposed. 

8  COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following: 

(a) 
(b) 
(c) 

, Mr. Friend’s daughter; 

, Director, Divine Health Services Ltd.; 

, Chief Executive, Herefordshire and Worcestershire Health and 

Care NHS Trust. 

I am also under a duty to send the Chief Coroner a copy of your response. 

The Chief Coroner may publish either or both in a complete or redacted or summary 
form. He may send a copy of this report to any person who he believes may find it 
useful or of interest. You may make representations to me, the coroner, at the time of 
your response, about the release or the publication of your response by the Chief 
Coroner. 

9 

18 September 2023 

David REID 
HM Senior Coroner for Worcestershire 

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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1) 

, Director, Divine Health Services Ltd., Unit 59, 

Basepoint Business Centre, Isidore Road, Bromsgrove, Worcestershire B60 
3ET. 

1  CORONER 

I am David Donald William REID, HM Senior Coroner for Worcestershire. 

2  CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 
2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 

3 

INVESTIGATION and INQUEST 

On 25 April 2023 I commenced an investigation and opened an inquest into the death 
of Anthony John Friend. The investigation concluded at the end of the inquest on 5 
September 2023. 

The conclusion of the inquest was that Mr. Friend died as the result of an accident. 

4  CIRCUMSTANCES OF THE DEATH 

In answer to the questions “when, where and how did Mr. Friend come by his death?”, 
I recorded as follows: 

“On 17.4.23 Anthony Friend, who was living with the effects of a brain tumour and 
required regular personal care visits at his home in Bromsgrove, sustained a 
significant head injury after slipping through a sling while being hoisted from a chair to 
his bed, and striking his head on the frame of the hoist. He was discharged from 
hospital back home for palliative care, and declined and died there on 20.4.23. The 
sling being used at the time of the fall had previously been adjudged unsuitable for his 
care needs, but it was not removed from his property, and no instruction had been 
given that its use should cease.” 

5  CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern. 
In my opinion there is a risk that future deaths will occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.  – 

In the course of the inquest, I heard evidence that: 

1)  Bluebird Care provided care at home for Mr. Friend up to 16.4.23 ( two days 

2) 

before the accident which led to Mr. Friend’s death ); 
the reason Bluebird Care stopped providing care for Mr. Friend was that they 
had concerns about the sling which was still being used with his hoist; 
3)  Bluebird Care knew by 12.4.23 that Mr. Friend’s care at home after 16.4.23 

would be provided by Divine Health Services Ltd.; 

4)  At no time did Bluebird Care try to make contact with, or provide any sort of 
handover to Divine Health Services Ltd. about Mr. Friend’s needs, or about 

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 any concerns they had concerning the sling. In her evidence to the inquest, 

, Bluebird Care’s registered care manager, agreed that it was 

“common sense…for there to be a good handover between care agencies”, 
but that it “was not something which we had ever done”; 

5)  At no time did Divine Health Services Ltd. make any efforts to identify, contact 

or seek a handover about Mr. Friend from the previous care agency Bluebird 
Care. In his evidence to the inquest,
, Director of Divine 
Health Services Ltd., agreed that it would be “a matter of good practice” to 
have done so. 

6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you, as 
the Director of Divine Health Services Ltd., have the power to take such action. 

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 13 November. I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting 
out the timetable for action. Otherwise you must explain why no action is proposed. 

8  COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following: 

(a) 
(b) 
(c) 

, Mr. Friend’s daughter; 

Director, Bluebird Care; 
Chief Executive, Herefordshire and Worcestershire Health and 

Care NHS Trust. 

I am also under a duty to send the Chief Coroner a copy of your response. 

The Chief Coroner may publish either or both in a complete or redacted or summary 
form. He may send a copy of this report to any person who he believes may find it 
useful or of interest. You may make representations to me, the coroner, at the time of 
your response, about the release or the publication of your response by the Chief 
Coroner. 

9 

18 September 2023 

David REID 
HM Senior Coroner for Worcestershire 

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Bluebird Care (Bromsgrove & Redditch) 
3 Millennium Court, Buntsford Park Road 
Bromsgrove, B60 3DX 

Mr David Reid  
HM Senior Coroner for Worcestershire  
Worcestershire Coroner’s Court 
The Civic 
Martins Way 
Stourport-on-Severn 
Worcestershire 
DY13 8UN 

BY EMAIL ONLY  

Dear Sir 

Inquest touching upon the death of Anthony Friend 

I write in relation to the Regulation 28 report sent to Bluebird Care Bromsgrove & Redditch 
regarding the death of Anthony John Friend dated 18 September 2023 and received on 29 
September 2023. 

Following on from the inquest and receipt of the Regulation 28 report, we have thoroughly reviewed 
the circumstances surrounding Mr Friend's case, both in relation to Bluebird Care and other health 
care providers and professionals involved. We are always committed to being an outstanding care 
provider and will take any feedback on board to improve our processes.  

We note that the Coroner has expressed concern that there was no direct contact between 
ourselves, as the outgoing provider of care, and the incoming provider in this matter and he is 
concerned that this may have led to important information, such as concerns, not being passed on. 

We are conscious that the question of handover processes between NHS Continuing Health Care 
("CHC") commissioned care providers arose during the course of the inquest. It therefore may be 
helpful for us to provide some additional context to this process via this response which may assist 
in allaying HM Senior Coroner's concern in this regard. 

NHS Continuing Health Care (CHC) refers to packages of care that are arranged and funded solely by 
the NHS Integrated Care Boards for individuals over the age of 18 years who have been deemed to 
have a ‘Primary Health Need’ and have ongoing complex, intense or unpredictable healthcare needs. 
These packages are overseen by Clinical healthcare professionals such as Clinical Nurses, and 
managed by the CHC teams at the relevant NHS Integrated Care Boards. 

Bluebird Care Bromsgrove & Redditch  
Registered in England and Wales as R D (Bromsgrove) Ltd. Company No. 7099683 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 Bluebird Care (Bromsgrove & Redditch) 
3 Millennium Court, Buntsford Park Road 
Bromsgrove, B60 3DX 

The standard practice of handover of a CHC care package between care providers, as was followed in 
this case, is below: 

1.  Notice is served on the Hereford and Worcester CHC team by the outgoing care provider; 

2.  A detailed verbal update and handover is provided by the outgoing provider to CHC's clinical 

case handlers. This handover would include outlining any areas of concern; 

3.  The CHC care plan is updated to include any additional information provided by the outgoing 

provider and this is shared with brokerage to seek a new provider;  

4.  The new provider will review and assess the patient, request/obtain any information they 

require (including from the outgoing provider if necessary) and, if satisfied, the new provider 
will agree to commence care; 

5.  The outgoing provider will cease providing care, the new provider will commence providing 

care. The identity of the new care provider is not typically shared with the outgoing 
provider. 

In our experience, the care plans prepared by the CHC clinical case handlers are generally detailed 
and informative. 

Following the inquest, the senior management team at Bluebird Care Bromsgrove & Redditch carried 
out a ‘Lessons Learned’ meeting on 5 October 2023 to review Mr Friend's case in more detail. The 
aim of this meeting was to highlight and discuss what went well with his care, what could have gone 
better and also if there were any improvements to be made to any processes. This meeting provided 
an opportunity for us to consider the Regulation 28 report carefully. 

As part of this meeting, the management team reviewed the detailed care plan that had been 
prepared by CHC based on information provided by ourselves and provided to Divine Health Care as 
part of the process of finding a new care provider. Although the handover was from CHC to Divine 
Health Care and not directly from Bluebird Care to Divine Health Care, all of Bluebird Care’s concerns 
regarding the sling were very clearly documented within this detailed 14-page document. Our 
identity as the outgoing care provider was also included within this document. This document was 
shared with Divine Health Care in advance of them carrying out their assessment and agreeing to 
take over Mr Friend's package of care. 

Bluebird Care Bromsgrove & Redditch  
Registered in England and Wales as R D (Bromsgrove) Ltd. Company No. 7099683 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Bluebird Care (Bromsgrove & Redditch) 
3 Millennium Court, Buntsford Park Road 
Bromsgrove, B60 3DX 

As outlined at the inquest, Bluebird Care had concerns regarding the positioning of Mr Friend’s neck 
whilst being hoisted in the sling, and the possibility of restricting his airways and oxygen levels, as 
opposed to any concerns around the possibility of Mr Friend falling from the sling. The concerns 
highlighted by Bluebird Care around the neck positioning are what led to the review of the sling by 
Occupational Therapists. 

Whilst, as above, we do consider that in this case the handover process captured all the relevant 
information we had to share with the new provider, in an effort to improve this process going 
forward  we have written to Herefordshire and Worcestershire CHC to seek guidance and 
clarification on the existing handover protocol for care providers when either taking on, or serving 
notice on, a package of care from CHC, as well as establishing best practice standards to implement 
any possible improvements. We are dedicated to continue to be a high-quality care provider, and 
although the circumstances are unfortunate, we want to take this opportunity to work in 
partnership with other health care professionals to provide the best care and support to all those 
that we support.  

This is important not only for Bluebird Care, but also for all other health care providers supporting 
users of services that may be transitioning from one service or provider to another, and most 
importantly for those that we support. Within our letter to Herefordshire and Worcestershire CHC, 
we also urged them to review the processes in place for all care providers. 

Within the letter, we have requested the following steps are taken when a transfer of care provider 
is being planned or contemplated: 

1. 

2. 

If we take on a package of care from CHC, we request that we are informed of the identity 
of the outgoing care provider so, alongside the care plan provided by CHC, we are able to 
seek any further information from the outgoing provider that we may require. 

If we serve notice to CHC on a care package (i.e. we become the outgoing care provider), we 
would like our information to be provided to the new care company, allowing us to provide 
a direct handover to them. This would be in addition to any handover we already provide to 
CHC. We also request that CHC inform us of the new provider to allow us to offer any 
support/information to them to make the transfer of care as seamless as possible. 

3. 

If we serve notice on a package and a new care provider is sourced, we would like them to 
be informed by CHC (if we have not already had an opportunity to do so ourselves) that the 

Bluebird Care Bromsgrove & Redditch  
Registered in England and Wales as R D (Bromsgrove) Ltd. Company No. 7099683 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Bluebird Care (Bromsgrove & Redditch) 
3 Millennium Court, Buntsford Park Road 
Bromsgrove, B60 3DX 

Bluebird Care folder will be in the Customer’s property, containing the customer’s care plan 
as well as an up-to-date list of tasks for each visit. 

4.  Where we are the outgoing provider, we would like to offer any new provider the 

opportunity to observe our care staff carrying out a care call so any necessary observations 
can be made and any questions asked. We would like to be given notice of when this would 
occur to ensure a senior member of staff can be present and ensure the most thorough 
handover possible. 

5.  We would also value the opportunity, should it be required, to observe a care call being 
carried out by an outgoing provider if we were to take over a package of care. We have 
proactively sought out these opportunities ourselves and have found them beneficial when 
circumstances require this, for example visiting a customer in hospital to make observations 
prior to returning home, and visiting another customer at home who had an existing 
homecare provider visiting daily. 

6.  We would request that CHC share the reasons that an outgoing care provider has served 

notice on a package. This would allow us to make a more informed decision as to whether 
we are in a position to take on the package of care, or if we would be likely to experience 
the same issues and concerns. It also allows us to pay particular attention to these key areas 
of concern, and conduct the relevant risk assessments to ensure the best and safest care is 
provided at all times.  

7.  We would also appreciate if, as a new care provider, we could be advised of any existing 

appointments the customer may have that would be helpful to know of e.g., occupational 
therapist visits. Likewise, we would share any appointments we were aware of with CHC, so 
the new provider could be made aware at the earliest time. 

From our perspective, this process will not be limited to handovers concerning CHC funded patients 
and will be followed for all customers that are transitioning to or from our care. 

We feel confident that if the above steps are adhered to by all parties, this will lead to better 
outcomes and a more robust handover process. In particular, the process will no longer be solely 
reliant upon information being passed between care providers by CHC clinical case managers, as 
there will be opportunities for direct handover between care providers and a conduit for sharing 
additional information as required. 

Bluebird Care Bromsgrove & Redditch  
Registered in England and Wales as R D (Bromsgrove) Ltd. Company No. 7099683 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Bluebird Care (Bromsgrove & Redditch) 
3 Millennium Court, Buntsford Park Road 
Bromsgrove, B60 3DX 

As a care provider, the safety and wellbeing of those we provide service to is paramount. Despite the 
unfortunate circumstances in which these issues have arisen, we welcome the opportunity HM 
Coroner has provided for us to revisit Mr Friend's case in order to learn from this experience and 
implement steps to ensure that we continue to provide the best quality care. 

We are aware that this response will be shared with the family. We wish to reiterate our sincere 
condolences to them on the loss of Mr Friend. We also wish to thank them for their kind comments 
at the inquest about the quality of care we provided.   

Yours faithfully 

Director 
Bluebird Care Bromsgrove & Redditch 

Bluebird Care Bromsgrove & Redditch  
Registered in England and Wales as R D (Bromsgrove) Ltd. Company No. 7099683

Chief Executives Office 
2 Kings Court 
Charles Hastings Way 
Worcester 
WR5 1JR 

7 November 2023 

Mr D D W Reid  
HM Senior Coroner  
Worcestershire Coroner’s Court 

Dear Mr Reid, 

Re:   The Late Anthony John Friend 

Regulation 28 report to prevent future deaths - response  

Thank you for forwarding on your Regulation 28 report.  I have read your report with great 
care and note the concerns that you have raised during your inquiry concerning the death of 
Mr Anthony Friend. 

In your report, you highlighted the following points of concern, and I will respond to these 
individually: 

1.  As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. 

Friend’s death), an Occupational Therapist employed by HWHCT, had concluded 
that the sling being used at the time of the accident on 17.4.23 ( the “old toileting 
sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable 
slings were provided instead, but did not remove the old toileting sling from Mr. 
Friend’s home. 

2.  During a home visit to Mr. Friend’s address on 2.2.23, noted that the old toileting 
sling was still being used, made clear to Mr. Friend’s family and carers that it was 
“not safe to use”, but again did not remove it from the property; 

3. 

 During a home visit to Mr. Friend’s address on 6.3.23, another Occupational 
Therapist employed by HWHCT, noted that the old toileting sling was still being 
used by family and carers, and that although the two more suitable slings provided 
by her colleague would be difficult to fit, they were nonetheless safer to use. She 
told the inquest that in hindsight she “should not have allowed [carers] to carry on 
using the unsafe sling” and that she did not know why she had not taken time to 
show carers how to use the safer slings which had been provided; 

 
 
 
 
 
 
 
 
 
 
  
 
 
  
 
 
  
 
 
 
 
 
 
 4.  During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident) in 
order to assess Mr. Friend for a new sling, noted that the old toileting sling was 
still being used. However, she told the inquest that despite her misgivings about it, 
she did not remove it from the address, and still expected carers to carry on using 
it for the next two weeks until a new sling arrived. She described this decision as 
“an oversight” on her part; 

5. 

 also told the inquest that; 
(a) she should have ensured that Mr. Friend’s carers were present for the 
home visit and sling assessment on 17.4.23 (which they were not); and 
(b) she should have contacted his new carers (Divine Health Services Ltd.) 
after that visit, to discuss their use of the sling. 

As a Trust we recognise that at the time of this incident we did not have a robust policy and 
procedure in place to support our staff in the community with regard to the removal of unsafe 
equipment. Since the inquest we have formulated a working group to design a new policy 
around equipment provision and this will cover the necessary steps and procedures for our 
staff, around timely removal of unsafe equipment from a patient’s home. We will have this 
new policy signed and operational by the 1st April 2024. A key element will be sharing this 
new policy which will be completed at individual team meetings and via our global all staff 
communication emails. Whilst we are developing the new policy we have issued more 
immediate instructions to staff via a focus on card approach. 

As a Trust we recognise that more timely action was required about removal of older slings 
so we have in partnership with a range of professionals designed a focus-on-card around a 
step by step guide for staff when they identify unsafe equipment in a patient’s home. This is a 
direct impact from this serious incident. This will act as a useful reminder document that staff 
will have access to when visiting patients in their homes and will be a vital part of new 
starter’s induction packs.    

In addition, this card has been shared at operational meetings and globally on 28 September 
2023 via our communication team with all Trust staff; a copy of the card is attached for your 
information. As part of this all clinicians are now carrying laminated cards- “unsafe 
equipment- do not use”, these can then be attached, photographed using NHS mobile 
telephones and uploaded to our electronic patient record system (EPR) as evidence, 
supported by supporting documentation. We recognise that this action may have alerted the 
care agency in the case of Mr Anthony Friend to not use the equipment. All  occupational 
therapy staff have been educated via a powerpoint presentation on when to use the cards. 
Staff have reported they are supportive of the implementation of this card. 

We have also designed a standardised template letter (a copy is attached for your 
information) for service leads to send to patients if our clinicians experience resistance when 
removing equipment from a patient’s home and these will be stored on our electronic patient 
record. 

We are also reviewing our manual handling and sling training that is provided to our staff to 
ensure this is adequate to support patient needs in the community. We are creating an 
algorithm to support staff decision making around when and what type of sling is suitable in a 
variety of situations. We hope to have this operational in the next 3 months.  Early 
discussions have taken place regarding additional online training that illustrates various 
clinical scenarios, identifying risks and potential equipment that could be recommended. 

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 We also identified that as a service we need to ensure we have more robust documentation. 
All staff attend annual clinical records training but since this inquest we have also 
implemented a quality improvement record keeping audit with our HASE/OT services to 
ensure compliance with national, regional, professional and local record keeping 
requirements. 

6.  At no time do either appear to have communicated their concerns about the 

continued use of the old toileting sling in writing to either of the agencies which 
were providing care for Mr. Friend at the relevant times. 

The Trust fully recognises that there was a breakdown in communication between the 
external agencies involved in the care of Mr Anthony Friend.   
We have since the inquest designed and introduced a new leaflet (copy attached) that is given to 
all our patients on initial assessment with the Housing, Adaptation and Specialist Equipment 
service (HASE). This leaflet has our contact details on. Any family can then easily and accessibly 
share these details with care agencies if required. This leaflet can also be used by other 
stakeholders including our GP colleagues when they refer patients to our service. 

We have also introduced a new role into our countywide service, this role has a significant bias 
towards improving communication with our external agencies to prevent occurrences like this 
happening again.  They will be involved in joint visits to clients and will have weekly clinical 
supervision, where tasks will be delegated to them to support improved communication between 
HASE and other agencies. 

As a Trust we have a robust incident reporting system and are passionate about sharing 
learning from incidents and complaints   with our colleagues in a supportive and 
compassionate manner with an aim of preventing any further incidents of this nature 
occurring. The Trust Board are well sighted via the  quality report on incidents and 
complaints. 

I hope this reassures you that the Trust has taken action to improve standard operating 
procedures around unsafe equipment in the community and to improve communication with 
external agencies through the development of new roles and leaflets. The Trust is committed 
to learning from this incident to avoid any similar occasions of staff not removing equipment 
when it is no longer appropriate to be used. 

I hope that the above adequately addresses your concerns. 

I shall be grateful if you could kindly send a copy of my response to those to whom you copied 
your Regulation 28 report. 

Yours sincerely 

Chief Executive 

Encs 

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