Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0482, written 27 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Nov 2023 |
|---|---|
| Reference | 2023-0482 |
| Deceased | Barbara Rymell |
| Coroner | Samantha Marsh |
| Coroner area | Somerset |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The Home Office
2 Marsham St, London SW1P 4DF
2. Helen Whatley MP, MP for Department of Health and Social Care
1 CORONER
I am Mrs Marsh, Senior Coroner for the coroner area of Somerset.
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.
3
INVESTIGATION and INQUEST
On 9th August 2022 I commenced an investigation into the death of Barbara
Jean Rymell, aged 91 (“Barbara”).
The investigation concluded at the end of the inquest on the 21st of November
2023.
The conclusion of the inquest was death by Misadventure. The medical cause
of death was recorded as:
Ia) mechanical obstruction of respiration
Ib) presumed fall downstairs
Ic) –
II) senile myocardial atrophy, dementia, general frailty.
I recorded in box 3 of the Record of Inquest that:
Barbara Jean RYMELL, aged 91, was left unattended on a mechanical stair lift
at her care home (Ashley House Residential Home) on the evening of the Eighth
of August 2022. Risk assessments identified that Barbara was not permitted to
use the stair lift unaccompanied or unattended due to her physical and cognitive
limitations. Whilst left unattended, Barbara has left the mechanical chair and
proceeded to try and ascend the stairs. She has fallen causing her head to
become wedged in between the chair seat and the stairs at an awkward angle,
meaning it was not possible for care home staff to free her, or administer first aid
due to her body position. Barbara’s breathing was compromised as a result of
her entrapment, and she was pronounced deceased on the arrival of the
paramedics.
1
4 CIRCUMSTANCES OF THE DEATH
Barbara became a resident of Ashley House Residential Home in Langport
(“Ashley House”) on the 8th August 2022. She took up residency on discharge
from hospital where she had had an inpatient stay as a result of a fall in the
community.
On becoming a resident of Ashley House Barbara had a known diagnosis of
dementia, which sometimes affected her memory. She was at a high risk of
falling and had blurred vision. All in all, she was a relatively frail elderly woman
with known risks around her mobility and she relied on others to keep her safe.
Barbara was the only resident with a bedroom on the first floor of Ashley House.
This could only be accessed via the stairs (which Barbara was incapable of
ascending or descending safely) or the mechanically operated stairlift (which
Barbara was not permitted to use unattended or unsupervised.)
On the evening of the 8th of August 2022 two carers were on duty; neither of
whom were native English speaking nationals; one was Romanian and the other
was Indian.
I was told that in order to be able to work in the UK, those requiring a Visa (as
the two carers on duty did) must prove that they can read, write, speak and
understand English to at least Level B1…. [that they must demonstrate that
they] can understand the main points of clear standard input on familiar matters
regularly encountered in work”. Applicants for a Visa must have passed a
Secure English Language Test (SELT).
It transpired during the Inquest that one of the workers on the evening of the 8th
August 2022 had never passed the SELT, so was not qualified or permitted to
work in the UK.
At 19:27 one of the carers called 999 to request an ambulance. It was clear, on
the evidence, that Barbara had been left unattended on the mechanical chair for
around five minutes. This was clearly contrary to the rules and procedures of
Ashley House. During those five minutes she has left the seat of the
mechanically operated stairlift (possibly unfastening the seat belt) and
proceeded to climb the stairs; which she was unable to safely, due to do
physical limitations and her underlying cognitive impairment.
She has fallen on the stairs, falling downwards. There were no witnesses to this
incident but Barbara has been found, having fallen awkwardly, landing with her
head trapped under the chair for the mechanically operated stairlift. Care staff
were unable to free her because of the positioning and angle at which she was
entrapped within the mechanics.
On calling 999 (copies of both recordings were played at the Inquest) it was
obvious that neither of the care staff were sufficiently proficient in English to be
able to:
(i) Explain clearly the nature of the medical emergency. An internal audit by
the ambulance service revealed that the call-handler had selected an
incorrect pathway. The correct pathway that should have been selected
was “entrapment” but at no time during the call did the carer give any
information that would have indicated that this was the presenting
2
problem. The carer repeated used the word “blocked” which added no
assistance, clarity of explanation of the events that were unfolding.
(ii) Understand the difference between “bleeding” and “breathing”. This
made any meaningful triage of Barbara’s condition virtually impossible.
The call handler followed the script to ask if the patient was conscious
and breathing (i.e. to ascertain clinical emergency and determination of a
priority response) but this assessment was severely hampered given the
carer did not appear to know or understand the difference between
bleeding and breathing.
(iii)Understand the difference between “alert” and “alive”, which presented all
of the same problems as referred in in (ii) above.
Paramedics arrived on a category 2 response and, on arrival, it was clear that
Barbara was beyond medical help. She was pronounced deceased at the
scene.
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 could occur unless
action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
I am concerned that those working with vulnerable people who are in a position
of trust and responsibility must be able to demonstrate a sufficient proficiency in
English to enable to summon appropriate emergency medical attention when
needed. Vulnerable people, by very definition, are unable to often appreciate
the need for help; take steps to keep themselves safe and/or summon help for
themselves when they need it.
By being unable to speak the native language of England with any proficiency I
am concerned that deaths will continue to arise where those who are young,
disabled, suffering from a mental impairment or who are elderly and in need of
urgent medical help will not have this summoned for them if those who are
engaging with emergency professionals are unable to communicate effectively.
The Court looked at evidence of the B1 English test. Examples from the paper
were as follows:
“I __________ that book last year” (options are bought, have bought, had
bought)
“The town, ________ is very beautiful, has lots of parks” (options are which,
where, what).
This level of comprehension is comparable to a KS2 curriculum being studied by
Year 6 students sitting their SATS exam and appears to be wholly insufficient for
those working in the direct care and protection of vulnerable people, as
demonstrated in this case by carers who were alone (i.e. no English speaking
members of staff on duty) being unable to explain to medical professionals the
presenting condition of the patient.
3
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has 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 Monday 22nd January 2024. 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
Interested Persons:
(i) Barbara’s immediate family
(ii) The CQC
I am also under a duty to send a copy of your response to the Chief Coroner
and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I believe may
find it useful or of interest.
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.
9
27th November 2023
4
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Tom Pursglove MP
Minister of State for Legal Migration
and the Border
2 Marsham Street
London SW1P 4DF
www.gov.uk/home-office
Samantha Marsh
Senior Coroner for Somerset
Coroner's Office
Old Municiple Building
Corporation Street
Taunton
TA1 4AQ
4 January 2024
Dear Mrs Marsh,
Thank you for your letter of 27 November 2023 to the Home Office, following the
investigation into the death of Barbara Jean Rymell. I am replying as the Minister of State
for Legal Migration and the Border.
I would like to start by expressing my sincere condolences to the family and friends of
Barbara Jean Rymell. I would also like to place on record my thanks to you for this
investigation and for raising the matter of concern contained within your report.
Unfortunately, the information provided to us by your office has not allowed us to
determine the immigration status for those individuals involved in this case. This means we
cannot confirm whether they were on an immigration route which required them to
demonstrate English language as part of their application or not.
The immigration system contains a wide variety of routes which allow people to come to
the UK to work, study, for cultural exchange, and as dependants joining family members.
The English language requirement for immigration purposes has two functions. The first is
to ensure the person can undertake the activity for which they are coming to the UK, for
example to study or, if working, the job, including understanding any safety information
relating to the job and to be able to bring any concerns to their employer.
The second function is to help migrants to integrate into the UK. This will include ensuring
they can engage with local services such as healthcare, education, and other public
services which people will need to use in their day-to-day lives.
Both are important, and we believe strike a balance between ensuring the safety and
integration of migrants and the ability of businesses to bring in the labour they need.
Importantly, these immigration requirements are the same for all sectors who are eligible
for Skilled Worker visas and reflect the level of English which is necessary should people
wish to apply for indefinite leave to remain and ultimately citizenship if they choose.
I receive representations on a regular basis from sectors who argue that the English
language requirements are too high for their sector. Unfortunately, it would prove very
difficult, both to assess and also to manage, a system where we had different English
language requirements for different occupations.
Since February 2022, the main route for care workers wishing to come to the UK has been
through the Health and Care visa, which is part of the wider Skilled Worker visa. Those
arriving on the Health and Care visa must demonstrate that they meet the ‘B1’ standard,
and details of the levels can be found at: https://www.coe.int/en/web/common-european-
framework-reference-languages/table-1-cefr-3.3-common-reference-levels-global-scale.
English language can be proved in various ways, but the most common is through passing
a Secure English Language Test (SELT). Alternatively, they can meet the requirement if
they are from one of the listed majority English speaking countries, or if they have a
suitable qualification which was either taught in the UK, or taught or researched in English.
Qualifications obtained outside the UK need to be confirmed by ECCTIS. ECCTIS
provides official UK national agency services on behalf of the UK Government in
qualifications, skills, and migration.
However, there are a number of immigration routes, other than Skilled Worker, where
individuals are permitted to work, without first needing to seek approval from the Home
Office. These include dependants of workers or students. Dependants, which is defined as
a partner or children under 18 years of age, are not required to work, but where they
choose to, do not need permission from the Home Office for any employment. Dependants
are also not required to demonstrate that they meet the English language requirements
unless they are applying for indefinite leave to remain (settlement).
There are a range of other routes which have general work rights, including those on the
Hong Kong British Nationals (Overseas) route, those who have arrived through
humanitarian routes such as the Ukraine schemes, or Afghan relocation schemes,
recognised refugees, and those who arrive under Youth Mobility Scheme arrangements.
The purpose of these routes varies from cultural exchange to humanitarian, but all permit
people to work whilst in the UK without seeking prior agreement and none of them have an
English language requirement.
In addition to those routes listed above, asylum seekers who have had a case outstanding
for more than 12-months, though no fault of their own, may also apply for permission to
work. Where this is granted, these individuals may only work in occupations contained on
the Shortage Occupation List. This would include as a care worker, which was added to
the list of shortage occupations in February 2022.
This creates a mix of immigration routes with different purposes, but where people could
end up working in social care. Raising the English language level in those routes which
have an English language requirement would be very difficult, and imposing such a
requirement on routes which do not have such a requirement would in some cases defeat
the purpose of the route as it was intended.
I absolutely recognise that ensuring the safety of those who require care is a very
important issue, but the responsibility for ensuring that employees can fulfil the
requirements of their role primarily rests with employers. An employer should ensure their
overseas staff can speak English to an adequate standard. The employer should consider
the merits of requiring higher levels of English language than necessitated by immigration
requirements – on the basis that it may be required for the settings overseas staff will be
working in. In some cases, a higher level of English than required for a visa may be
required to work in a particular role. This is already the case for many health and care
workers who require professional registration. For example, the Nursing and Midwifery
Council require a higher level of English before a nurse can join their register. The same is
true of doctors who must register with the General Medical Council, dentists with the
General Dental Council and many allied health professionals who are required to be
registered with the Health and Care Professions Council. All of these bodies have
language requirements for those working in the profession which are higher than the
requirement set by the immigration system.
Unlike those listed above, there is no requirement for care workers to be registered with a
professional body, but an employer or organisation must be registered with the Care
Quality Commission (CQC) where the organisation is providing regulated services. The
CQC provides regulatory oversight of the quality and safety of care provided by health and
care providers. Under regulation 19 of the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2014, employees are required to have the qualifications,
competence skills and experience which are necessary for the work to be performed by
them. It is the responsibility of a care provider to ensure the individuals they hire are
suitable for the role. To meet this regulation, providers must ensure they have robust
recruitment procedures, undertaking relevant checks, and a procedure for ongoing
monitoring of staff to make sure they remain able to carry out the duties required of them.
Given the points which I have set out above, we do not believe that raising the level of the
English language requirements for Skilled Workers would be appropriate, nor do we think
it would be practical to set different levels for different sectors. In any event, it would not
fully address the concerns you have raised for all the reasons set out earlier.
However, the Government has recently announced that it will tighten the requirements for
care workers coming to the UK on the Health and Care visa. Most relevant is the fact that
only care providers who are regulated by the CQC will be eligible to sponsor care worker
and senior care worker applications from Spring 2024. We will keep immigration
requirements, including those relating to English language, under review as part of this
work.
Yours sincerely,
Tom Pursglove MP
Minister of State for Legal Migration and the Border
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