Sylvia Nash

REPORT FOR HER MAJESTY’S CORONER FOR 
THE BIRMINGHAM AND SOLIHULL AREAS 

Re: (Sylvia Nash) 

(deceased) 

DATE OF BIRTH: 30/05/1940 

DATE OF DEATH: 14/04/2023 

ADDRESS - LATE OF: The Orchards Care Home, 164 Shard End 
Crescent, Shard End, Birmingham B34 7BP 

OFFICIAL 

 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
           
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
                         
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Report prepared by: 

Role: Head of Service - Hospital and Discharge to Assess Pathways 

Background 

This  response  is  provided  by  Birmingham  City  Council  (BCC)  further  to  the  Regulation  28 

Report issued by HM Assistant Coroner Rebecca Ollivere on 2 January 2024. I would like to 

start by expressing our condolences to Sylvia’s family for their sad loss. 

The Assistant Coroner explained in the Report that she is concerned that the communication 

and  understanding  of  the  correct  process  between  agencies  around  decision  making  is 

insufficient.  Prior  to  the  report  being  issued,  BCC  had  written  to  the  Assistant  Coroner 

acknowledging  shortcomings  which  had  existed  at  the  time  and  setting  out  in  detail  the 

changes  which  have  been  made  to  its  processes  since.  That  already  being  the  case,  the 

Assistant Coroner has requested that BCC’s Regulation 28 response should address only the 

issue of communication between services. 

BCC Social Workers work alongside partner agencies and professionals to support the social 

work assessment process, as an example, they will refer citizens to therapy services and then 

on receipt of the therapy report, review the recommendations and use them to underpin and 

provide an evidence base as part of their own Social Work (“SW”) assessment.  Information 

sharing  between  partner  agencies  takes  place  in  a  variety  of  forms  depending  upon  the 

service.  There  may  be  daily  board  rounds,  tracker  meetings  or  Multi-Disciplinary  Teams 

(“MDT”).  The  purpose  is  to  ensure  that  all  professionals  supporting  the  citizen  have  a  full 

understanding of all of their care and support needs, so this includes both health and social 

care needs.  It is also an opportunity to identify if there may be any disagreements between 

professionals and what actions are required in order to ensure a safe discharge. 

Citizens will be discussed within the MDT at various stages of their assessment journey – for 

instance following a therapy assessment, the MDT will be updated about their mobility needs, 

following  a  capacity  assessment,  the  MDT  will  be  updated  about  the  citizen’s  capacity  etc. 

Where there is a disagreement around a citizens’ care needs, there needs to be a discussion 

within the MDT based on evidence. The expectation is that a consensus can be reached within 

the  MDT,  if  this  is  not  possible,  then  any  concerns  need  to  be  clearly  documented  on  the 

OFFICIAL 

 
 
 
 
 
 
 
 
  
 
 
 
   
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
   
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 citizens care record. There are, at times, different professional perspectives. Social Workers 

are aware that if these cannot be resolved, they need to be very clear about their own decision-

making process and escalate when necessary to their line manager. Any decisions made need 

to include any risk mitigations where appropriate and again these need to be recorded on the 

care record. 

There may be a requirement for a Continuing Health Care assessment to identify any primary 

health care needs; the outcome of this will also inform the SW assessment and support with 

discharge planning. This is a separate multi-disciplinary process led by health and affords an 

additional opportunity for multi-disciplinary discussions. 

Once all assessments have been concluded, the MDT will be updated about the next stage in 

the process. This may lead to a commissioned service and the MDT will be notified about any 

offers received via Local Authority brokerage. Where a care home is being explored, the SW 

will send  a  copy  of  the  support  plan  via  email to the  potential  provider  and  follow  up  with  a 

telephone  call  to  arrange  the  pre-admission  assessment.  They  will  also  advise  the  existing 

service 

that  a  pre-admission  assessment  has  been  arranged.  The  pre-admission 

assessments  may  be  face  to  face  or  a  telephone  assessment.  It  is the  responsibility  of  the 

Social Worker to ensure that the support plan is up to date, and an accurate reflection of the 

citizen’s  care  needs  and  it  is  the  responsibility  of  the  existing  service  to  provide  a  full  and 

comprehensive handover for any pre-admission assessment.  Once a citizen’s care provider 

has  been  finalised,  the  MDT  will  be  updated,  and  the  discharge  will  be  arranged.  If  a 

professional has concerns around the proposed discharge, these would be explored and again 

during  the  board round/tracker/MDT meetings  and  should  be  recorded on the citizens’ care 

record.  All professionals working with the citizen will be aware that the citizen has an allocated 

social worker and the contact details for that worker. 

Information is shared between services in a variety of ways including face to face discussions, 

telephone calls, emails and reports. The expectation is that the citizens care record is kept up 

to  date 

to  reflect 

the 

information  sharing  between 

the  agencies 

involved 

in 

the 

assessment/discharge planning process. 

In Sylvia’s case, the care record does not evidence the multi-disciplinary input and decision-

making process. To address this, there have been staff engagement sessions and discussions 

with the Social Work staff around evidencing the multi-disciplinary decision making. There is 

now a template that workers need to complete to record the discussion, any agreed actions, 

and any risk mitigations. 

OFFICIAL 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Sylvia was a self-funder whilst living at The Orchards, and the care arrangements were made 

by the family and an independent broker.  BCC has a duty to complete the SW assessment 

for self-funders, this can then be shared with potential providers who will complete their own 

pre-admission assessment. This was the process followed for Sylvia. 

BCC  has worked  with colleagues in the Integrated Care Board (ICB) to develop procedures 

around 1 to 1 support.  The P2 (assessment) beds that Sylvia stayed in at Connaught House 

are funded by the ICB,  so  the ICB are taking  a lead  on developing this  and  embedding  the 

new  procedures  across P2  beds.  The  procedure  now  clearly states  that  1  to  1  support  can 

only be removed following an MDT decision involving the care home nurse, social worker, and 

the clinical need. 

BCC does not use Connaught House for P2 provision. However, the ICB when required does 

spot  purchase  beds  at  Connaught  House,  which the  ICB then oversees.  Discussions  have 

taken place between Connaught House and the ICB to ensure Connaught House understands 

that  responsibility  for  removing  1 to  1  support  does  not  sit  with  the  BCC  P2  team  but  is  an 

MDT decision, which should include the care home nurse, clinical lead, and the social worker. 

OFFICIAL

Further response from Connaught House 

Dear Ms Ollivere, 

Thank you for your follow up letter dated the 18th of March and for the opportunity to comment 
further. 

The email correspondence you kindly enclosed shows that Sylvia’s 1:1 observations were to be 
removed on the 3rd of February which was also the planned discharge date from Connaught House. 
To reiterate, Sylvia remained on her 1:1 observations whilst in our care at Connaught House.  

Had Sylvia not been due to leave our care on the 3rd of February we would have requested that we 
continue to have the 1:1 in place but monitor Sylvia from a distance for up to a week to ensure that 
the removal of the 1:1 was appropriate in our care setting at that time and did not pose a risk to 
Sylvia’s safety. We would then have reconvened with the Social Worker to discuss the result of 
monitoring Sylvia from a distance. This is a procedure we routinely follow when asked to remove 1:1 
care in each of our homes. 

As we outlined in our previous response the agreement to provide 1:1 observations is often a source 
of conflict between care homes and commissioners and there is often pressure to remove the 
enhanced observations. This is especially true when the resident who is in receipt of enhanced 
observations is settled as a result of this enhanced care. 

This was the situation with Sylvia and her 1:1 paperwork evidenced that she was settled for the 
majority of the time. It was our contention that she was settled as a result of the 1:1 observations 
and this was discussed with the social worker during discussions around the need for this enhanced 
care.  

The social worker was of the view that Sylvia did not need 1:1 care as her 1:1 paperwork reflected 
that she was settled for large periods. We contend that this was evidence of a well-met need but it is 
also true that the social worker was involved in making the placement at the Orchards Nursing Home 
and was in possession of information we did not have. For instance, following their pre-admission 
assessment, the Orchards Nursing Home may have decided that due to the fact that Sylvia was on 
1:1 care during the day she may be placed in a bedroom directly opposite the Nurse’s Station where 
she could be closely monitored. This is a clinical decision for another setting and we are not aware of 
their decision making process or what steps they had planned to take following their assessment. 

Our clinical decision was that Sylvia required 1:1 observations whilst in our care. We continually 
reevaluated and this was reduced to 12 hours during the day as we utilised our assistive technology 
during the night. It was the clinical decision of the Orchards Nursing Home that they could meet her 
assessed needs without the need for 1:1 supervision. It is worth noting that Sylvia was a resident of 
the Orchards Nursing Home for slightly longer that she was at Connaught House and any clinical 
decision should be subject to constant review. If they felt at any stage that Sylvia required 1:1 care 
then it was their responsibility to seek authorisation. 

We share your concerns regarding the MDT process regarding the removal of 1:1 funding and were 
very pleased to receive an email on Thursday 21st of March outlining a new process adopted by the 
ICB: 

OFFICIAL 

 
 
 
 
 
 
 
 
 
 
 
 “The ICB have put a new process in place whereby 1:1 can only be removed after our reviewer has 
discussed the safety of potential removal with the Care Home Nurse and the Social Worker. One 
person can’t remove the 1:1 in isolation.” 

We have ensured that this has been cascaded to our staff team and a poster has been placed in each 
nursing station to ensure that all involved in any 1:1 review are fully aware of this new process. We 
will also ensure that any visiting professional also fully considers the potential impact of the removal 
of 1:1 observations. 

Should you require any further information please do not hesitate to contact me. 

Yours sincerely, 

Operations Director 
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OFFICIAL

Ms Ollivere, 
Birmingham and Solihull Coroner’s Court, 
Steelhouse Lane. 
Birmingham 
B4 6BJ 

Dear Ms Ollivere, 

I am wri�ng in response to the Regula�on 28 Order that was made in rela�on to the sad passing of 
Sylvia May Nash following a fall at the Orchards Nursing Home and the inquest which took place on 
the 25th of September 2023. 

Sylvia was a P2 resident of Connaught House Care Home from the 31st of December 2022 un�l she 
le� to go to The Orchards Nursing home on the 3rd of February 2023. Sadly Sylvia sustained a 
fractured neck of femur following a fall at The Orchards Nursing Home on the 11th of March and 
passed away at Heartlands Hospital on the 14th of April 2023. As the fall occurred some 6 weeks a�er 
Sylvia le� Connaught House we were not invited to par�cipate at the inquest and this led to some 
confusion being created apparently by the evidence given during the inquest. 

Our care plans and risk assessments were clear that as Sylvia was at high risk of falls and subsequent 
injury. Sylvia required 1:1 supervision during the day and the use of our assis�ve technology at night 
and this was communicated consistently to the P2 team and the social work team who queried the 
need for 1:1 supervision with the Occupa�onal Therapy team. I note with concern that the Social 
Worker claimed during the inquest that she was “not sure what the ra�onale for placing Sylvia on 
one to one care was” as this was always abundantly clear to all as confirmed by our care plans, risk 
assessments and correspondence with the social worker and wider physiotherapy and occupa�onal 
therapy team. 

We assessed that in order to keep Sylvia safe she required 1:1 supervision whilst awake and the use 
of our bed and door sensors along with acous�c monitoring at night. Sylvia was placed in our care for 
a period of assessment. We made it unambiguously clear that Sylvia required enhanced observa�ons 
to meet her needs and prevent her from falling. A P2 placement is made in order to fully assess the 
care needs of an individual in a more appropriate se�ng than a Hospital ward with a view to 
ascertaining the most suitable placement for long term care. The responsibility for funding lies solely 
with the commissioners and it is extremely telling that we have not been paid a single penny for the 
1:1 care that we provided for Sylvia during her stay with us.  

The Regula�on 28 Order suggests that Connaught House could make some changes to its procedures 
with respect to the cessa�on of 1:1 care and we strongly disagree with this conclusion. At no stage 
did Connaught House remove the 1:1 care for Sylvia and we kept this in place despite not being paid 
for this expensive provision. The P2 team are fully and solely responsible for the review of the care 
needs of any individual they place in a P2 bed and for the funding levels available to the new care 
se�ng they choose to send the resident to. Connaught House can only provide the informa�on but 
are not in any posi�on to dictate this decision in any way, shape or form. Similarly, The Orchards 
Nursing Home was responsible for assessing Sylvia’s needs and for their decision that despite Sylvia 
being in receipt of 1:1 care at Connaught House they decided that they could meet her needs 
without 1:1 enhanced observa�ons. 

Whilst we have the power to control the delivery of care within Connaught House, unfortunately we 
do not have the ability to decide the funding levels or care delivered once a resident leaves our care 

 
 and it is extremely concerning that seemingly a misleading impression has been given to the Coroner 
in this regard. We shared our full notes, our assessment of needs, risk assessments and 1:1 
paperwork with the Social Workers and The Orchards but unfortunately it appears that The Orchards 
did not carry out a face to face assessment. 

The Orchards Nursing Home carried out a telephone assessment and were made fully aware of 
Sylvia’s care needs and it is incumbent upon all providers of care to carry out a full assessment of 
needs before accep�ng the placement of a new resident. This assessment is specifically designed to 
ensure that the new home has sufficient informa�on to adequately meet the care needs of any new 
resident. However, should the care home believe that the resident has more significant needs than 
they previously believed it is also their responsibility to increase the care provided in order to meet 
the needs of the resident. This may involve the provision of 1:1 observa�ons which should be funded 
by either the ICB or the Council. Similarly, it is the duty of the commissioners to ensure that they 
meet the assessed care needs of the individuals whose care they fund. In this scenario the only 
agency that fully discharged its responsibility in respect to the care of Sylvia is Connaught House who 
provided the care at a loss whilst other agencies seemingly solely focussed on funding levels. 

In response to the numbered maters of concern: 

1.  Connaught House did not remove 1:1 observa�ons and indeed provided this care without 
being paid for its provision. Our decision making process for the provision of 1:1 care is 
absolutely clear and was followed by us at all �mes as evidenced by our con�nued provision 
of the enhanced care deemed necessary by our care plans and risk assessments. Our 
decision was that Sylvia required 1:1 care during the day and the use of assis�ve technology 
at night and this was effec�vely ignored by both the P2 team and The Orchards Care Home. I 
am unaware as to whether or not The Orchards Nursing Home is equipped with the same 
type of assis�ve technology but the P2 team and manager of The Orchards would/should be 
aware of this, and this informa�on should have played an integral part in the decision 
making process. 
I am unsure as to why the Council is sugges�ng that Connaught House, or indeed any other 
care home, has the power to decide the funding of care delivered by a different provider as it 
is clear from our experience that although we can decide that 1:1 care is necessary whilst a 
resident is in our care this doesn’t mean that the Council agree to this level of funding or 
indeed pay the invoices. The decision making process is a mul�-disciplinary process solely in 
the respect of the provision of informa�on but the decision to fund enhanced care or to 
make a placement in another care se�ng lies solely with the Council. This has been the case 
for every single resident that has ever been placed in a P2 bed and I am astounded the 
Council have now suggested otherwise.  

2. 

3.  We fully understand the procedure for 1:1 funding and have followed it at all �mes. The 

Order refers to the removal of 1:1 supervision and I reiterate that we did not remove the 1:1 
observa�ons which remained in place whilst Sylvia was in our care. Despite being furnished 
with an abundance of informa�on surrounding Sylvia’s care, the funding authority and The 
Orchards Nursing Home decided that Sylvia did not require 1:1 observa�ons. That 
responsibility and power rests with them and not with us. We desperately wish that we had 
the ability to demand funding levels for the residents in our care, or indeed the funding for 
those that leave our care, but sadly this is not the case. We can advise and demonstrate a 
need for funding but we cannot force the Council or ICB to agree to this funding. In that 
scenario we can only discharge our responsibili�es to the best of our abili�es and this is 
precisely what we did in rela�on to the care of Sylvia where we con�nued to provide and 

 fund the 1:1 observa�ons without being paid for the extra care hours which we, and we 
alone, believed to be necessary. We did not remove 1:1 observa�ons prior to transfer and 
provided ample evidence of our assessment that Sylvia required 1:1 care but this evidence 
was effec�vely ignored. 

4.  There is no issue with our communica�on or understanding of the need for 1:1 observa�ons 
and this again was ably demonstrated by the care we delivered to Sylvia and the informa�on 
we provided to the wider mul�-disciplinary team. I would be extremely interested in the 
changes the Council have undertaken to adopt in light of this Regula�on 28 Order as I believe 
the issue was not around our provision of informa�on but rather whether there was an 
acceptance that this level of care was required or whether the Council could find an 
alterna�ve placement that was cheaper. Connaught House did not decide that Sylvia needed 
to leave its care and nor did we decide that these 1:1 observa�ons were not required. This 
decision was taken by others. 

In conclusion I do believe the issue of commissioners refusing to con�nue to fund 1:1 observa�ons is 
a huge issue for the care of our most vulnerable residents and sadly this is repeated across every 
area we operate care homes in. Indeed, in other areas, ICB Commissioners are now dicta�ng that 
they will only fund 20 hours of 1:1 observa�ons per day despite agreeing that the resident requires 
24 hours of 1:1 observa�ons and use the excuse that they will sleep at some point during the 24 
hour period. This is quite simply unsafe and as an organisa�on we refuse to agree to this but other 
organisa�ons will acquiesce as there is an imbalance of power between the commissioner and the 
provider.  

I do not believe that it is within our power to make any changes to the way that funding is assessed 
or agreed by the Council or the ICB and we will con�nue to provide 1:1 care where we have assessed 
that it is required and con�nue to advocate for the residents in our care.  

As I believe there is a wider issue surrounding the issue of removal of funding for 1:1 placements, I 
would welcome a further discussion with the Coroner and do believe that future deaths can be 
prevented. Unfortunately, during the inquest the Coroner was not furnished with the correct 
informa�on regarding the process surrounding the funding or removal of 1:1 observa�ons and as a 
result the Regula�on 28 Order does not target the root of the problem. I would really appreciate the 
Regula�on 28 Order needs to be reviewed as I feel it is unfair and not factual against Connaught 
House. 

I also want to make you aware this s�ll con�nues to happen from the local authority, only last week 
did a family come in to collect their rela�ve from a P2 bed and we had not been informed by the 
social worker, when we rang the Social worker they advised they had asked the family to inform us, 
yet we are responsible for discharge paperwork, ordering medica�on etc. It is a clear failure on the 
ICB and Local authority, not Connaught House. 

Yours sincerely, 

Director of Opera�ons.