Angela Carpos

MiHomecare 
Cardinal House  
Abbeyfield Court  
Abbeyfield Road  
Nottingham, NG7 2SZ  

14 June 2024 

Assistant Coroner Melanie Sarah Lee 
Inner North London 
St Pancras Coroner’s Court 
Camley Street 
London  
N1C 4PP 

Dear Assistant Coroner Lee   

Report for the Prevention of Future Deaths following the Inquest into the death of Angela 
Carpos 

1.  I am the Chief Executive Officer of City & County Healthcare Group (“CCH Group”), the 
parent company of MiHomecare Limited (“MiHomecare”). I am writing to you on behalf 
of MiHomecare further to the Inquest into the death of Angela Carpos and the Report for 
the Prevention of Future Deaths dated 22 April 2024.  

2.  The training, supervision and guidance provided to care workers  

2.1. 

CCH Group has a dedicated Learning and Development team that is overseen 
by our Chief of Quality, 
 (Registered Nurse). The role of the Learning 
and Development team is to design and draw up the training delivered to staff 
members, and to then organise, facilitate and deliver this. 

2.2. 

The Learning and Development team consists of the following roles to ensure that 
learning materials are up to date, follow best practice and are delivered to our 
teams through blended e-learning and face to face workshops. 

2.2.1.  3  Learning  Content  specialists  –  who  are  responsible  for  the  design  and 
implementation of learning materials. They are managed by an experienced 
Head of Quality, who is also a Registered Nurse, 
, and supported 
by  experts  in  digital  learning  program  design.  Since  January  2024,  this  team 
now sits as a part of the CCH Group Quality Team. This structural change means 
that  there  is  close  collaboration  with  our  learning  content  that  is  not  only 
operationally but clinically led. 

MiHomecare Limited | Registered Office: Cardinal House, Abbeyfield Court, Abbeyfield Road, Nottingham, NG7 2SZ.   
Registered in England and Wales | Registration Number 03203080 | Part of CCH Group 

 
 
 
 
 
  
 
 
 
 
 
 
 
 Additionally, we have restructured our Best Practice Forum, and since March 
2024,  this  is  now  led  by  an  experienced  Head  of  Quality,  Craig  McCall.  This 
Forum  undertakes  best  practice  reviews  from  all  areas  of  our  organisation  to 
ensure  that  we  review  serious  incidents  and  trends  and  take  action  to  learn 
from these incidents or trends. This includes reviews of policy, ways of working, 
improvements  to  documentation  or  systems  and  training  initiatives.  Nicola 
Brown sits as a standing participant in these reviews to ensure that any learning 
from the Forum / reviews is reflected in / used to enhance training for our teams. 

2.2.2.  3 Regional Training Managers – who manage the timetables and ensure that 

training is delivered.  

2.2.3.  26 Trainers – who work regionally to deliver practical and face to face training 

locally to our teams. This team is overseen by 

, Chief of Staff.  

2.3. 

All of our trainers are experienced in social care and as a minimum hold a train 
the trainer qualification and an approved first aid and manual handling training 
qualification.  Many  of  them  hold  much  higher-level  qualifications  in  training, 
training 
specific 
training  or 
including  Level  3,  4  or  5 
qualifications.  Some have relevant post graduate qualifications also.  

social  care 

2.4.  When  new care workers  join  MiHomecare  or  other  companies  that  are part  of 
CCH  Group  they  receive  induction  training.  This  training  is  delivered  through  a 
blended  approach  with  e-learning  modules  and  practical  workshops.  This 
induction  training  covers  all  aspects  of  the  Care  Certificate1  and  includes  the 
core capabilities training for people with learning disability and Autistic people 
(Oliver  McGowan  Mandatory  Training  Level  1).  There  are  practical  workshops 
covering first aid, moving and handling and medication. 

2.5. 

In terms of refresher training, our revised Care Professional Development training 
(CPD  training)  has  just  been  launched.  This  annual  update  training  has  been 
redesigned and now includes relevant updates alongside scenarios to enhance 
understanding around the impact and consequences of decisions made by our 
care staff. It looks to expand knowledge as our care workers progress and to bring 
our training to life, linking these to outcomes for people under our care. This is an 
online modular course covering the following topics: Health and Safety; First Aid 
Awareness  (which  covers  choking  and  aspiration);  Moving  and  Assisting; 
Infection  Prevention  and  control;  Food  Safety;  Medication  administration; 
Handling  Information  (GDPR);  Record  Keeping  and  internal  communications; 
and Dementia Awareness. 

1 Developed by Skills for Care, Health Education England and Skills for Health, the Care Certificate is an agreed set of 
standards  that  define  the  knowledge,  skills  and  behaviours  expected  of  specific  job  roles  in  the  health  and  social  care 
sectors. The Care Certificate is made up of the 15 minimum standards that should be covered if you are 'new to care'. The 
Care Certificate Standards include: Understand your role; Your Personal Development; Duty of Care; Equality and Diversity; 
Work  in  a  person  centred  way;  Communication;  Dignity  and  privacy;  Fluids  and  nutrition;  Awareness  of  mental  health, 
dementia  and  learning  disability;  Safeguarding  Adults;  Safeguarding  Children;  Basic  Life  Support;  Health  and  Safety; 
Handling information; and Infection prevention and control.  

 
 
 
 
 
 
 
 
 2.6. 

Care workers receive supervisions at their relevant Branch Office every 3 months. 
We have a specific type of supervision called a themed supervision – one of the 
available  themed  supervisions  covers  choking  (and  is  in  the  process  of  being 
updated to cover aspiration / aspiration pneumonia – see paragraph 4.4.1). In a 
themed supervision, there will be scenarios that care workers need to answer and 
then Branch Office staff  will discuss the answers with them. Staff can raise their 
concerns regarding a client in the supervision as well. They will be provided with 
clear and accurate guidance.  

2.7. 

Care workers are also subject to competency assessments every 6 months. These 
are completed in a client’s home and we will observe care tasks to ensure these 
are  completed  as  expected  and  check  care  workers’  knowledge  by  asking 
questions. 

2.8.  We also have a suite of flash cards, posters and guidance available for staff. This 
ensures all the relevant guidance is available for staff if they are in any doubt or 
just want to know further details. The documents / information are available on 
employees’ work issued mobile phones. Posters are very useful as they are in the 
Branch Offices and staff when visiting can review these. We encourage staff to 
read all the guidance available on their phones and at the Branch Offices. These 
additional guidance notes and mechanisms are in place to support best practice 
and organisational learning, highlighting current trends in service delivery where 
there are concerns, or indeed any learning from a single event.  

2.9. 

All  of  our  operational  teams  (including  Branch  Managers  and  Regional 
Managers), as part of orientation and onboarding, are taken through key policies 
and operational guides, located on the CCH Group intranet. They are also made 
aware of the Intranet and how to navigate and search for information. They are 
supported  through  their  orientation  with  a  blended  approach  with  eLearning 
modules, face to face mentoring and support and additional coaching by our 
central support teams.  Mentoring and support also includes one to one support 
on where to find and how to use the systems we operate. 

2.10.  We  have  recently  launched  a  new  CCH  Group  app  –  called  CCH  Connect. 
Operational and care staff have instant access to key policies through this app. 
We believe this innovation will give our teams better visibility and in particular, it 
gives  another  platform  in  which  to  reach  out  to  the  teams  and  keep  them 
informed of organisational learning, policies, procedures, and resources.   

2.11.  All Branches that are part of CCH Group will be subject to the governance review 
program conducted by our Quality team. Whilst this covers a broad spectrum of 
areas, relevant to this Inquest it will ensure and check CCH Group’s expectations 
surrounding training, supervision and guidance are met and maintained. Where 

 
 
 
 
 
 
 
 issues are identified, improvement support plans are put in place for the relevant 
branch and action take to track and monitor the completion of those plans.  

3.  The role of care workers – choking and aspiration  

3.1.  We  considered  that  it  would  be  helpful  to  set  out  the  care  and  support 
MiHomecare  provides  and  the  expectations  of  care  workers  in  respect  of 
medical concerns / responding to medical incidents (including those related to 
choking and aspiration).  

3.2.  MiHomecare is a homecare provider that provides care and support to people 
within  their  own  homes  in  the  community.  The  care  and  support  MiHomecare 
provides  to  individuals  is  varied  and  will  depend  on  the  package  of  care 
commissioned, usually, by the local authority. Care and support tasks completed 
by  MiHomecare  care  workers  can  include  assistance  with  personal  care  (for 
example,  assistance  with  washing,  dressing  and  toileting),  assistance  with 
administering  medication,  assistance  with  meal  preparation,  and  support  with 
shopping  and  domestic  activities  (such  as  hoovering).  MiHomecare  does  not 
provide nursing care and whilst care workers receive basic first aid training, they 
are not trained medical professionals.  

3.3. 

The  first  aid  induction  training  currently  received  by  care  workers  covers  the 
following topics (please see paragraph 4.3 that discusses the updates that have 
been made to this training).   

3.3.1.  The principles and purpose of first aid and basic life support; 
3.3.2.  Understand and demonstrate the primary survey (DRABC); 
3.3.3.  Managing an unconscious casualty (how and when to seek help); 
3.3.4.  Demonstrate the recovery position (including knowledge on recovery position 

for potential spinal injury); 

3.3.5.  Understand  and  demonstrate  CPR  and  the  use  of  an  AED  (including 

knowledge around a DNACPR); 

3.3.6.  Understand  what  is  choking  and  what  is  aspiration,  the  similarities  and 

differences between the two conditions; 

3.3.7.  How to recognise when a person is choking; 
3.3.8.  How to recognise when a person is aspirating or at risk of aspiration (including 

the risk of developing aspiration pneumonia); 

3.3.9.  Understand and demonstrate emergency actions for a choking casualty (adult 

and child); 

3.3.10. Understand what actions to take when a person is aspirating; and 
3.3.11. How to recognise and deal with sudden illness and serious injury.  

3.4. 

The fundamental message care workers receive from their training is that if they 
have any concerns about an individual’s health and wellbeing these should be 
escalated as appropriate – e.g., to the Branch Office, the GP, the District Nurses, 

 
 
 
 
 
 
 
 3.5. 

3.6. 

111  and  /  or  999  depending  on  the  concern  and  the  urgency.  Where  care 
workers are escalating to a medical professional (e.g., a GP or a 111 / 999 call 
handler),  they  are  instructed  that  they  should  follow  any  guidance  and 
instructions provided by the professionals.  

Choking  occurs  when  there  is  an  obstruction  in  the  windpipe  causing  difficulty 
breathing.  This  obstruction  could  be  something  solid  such  as  food  or  a  foreign 
object. Often, when an individual is choking, they will show outward signs such as 
coughing,  gasping,  and  touching  their  throat.  If  care  workers  consider  that  an 
individual is choking, they are trained to follow a set emergency procedure that 
can be seen on the prompt card at Appendix 1.  

Aspiration is when a person inhales something into their airway that enters their 
lungs. In a fit and healthy person, the foreign substance irritates the airways and 
triggers coughing  and  the  foreign  substance  will  likely  be ejected. In  someone 
who is frail or elderly they may not notice the particles (or liquid etc.) going in and 
not feel the irritation and so they may not cough it out or be able to do this. As 
the substance inhaled by aspiration is not sterile, when it stays in the lungs it can 
cause infection – this can cause aspiration pneumonia.  

3.7.  When a person has a known risk of aspiration (e.g., sometimes individuals living 
with dementia have increased risks), there are precautions that can be taken to 
make it less likely (e.g., ensuring the individual is sat up straight to eat, prompting 
them  to  eat  slowly).  Notwithstanding  this,  it  will  not  always  be  obvious  that  an 
individual has aspirated something into their airway. Whilst we would expect care 
workers to be able to identify the potential signs of aspiration, the key action we 
would  expect  them  to  take  if  they  had  any  concerns  about  an  individual’s 
presentation or condition, would be to escalate for medical support, which in an 
emergency  situation,  would  involve  calling  999  for  assistance,  giving  the  call 
handler all relevant information and following any instructions given.  

4.  Actions taken in respect of choking and aspiration   

4.1. 

Prior  to  the  Inquest  into  the  death  of  Angela  Carpos  in  December  2023,  the 
Finchley  Camden  Branch  of  MiHomecare  (the  Branch  from  which  Ms  Carpos 
received care) had taken a number of actions relevant to the issues surrounding 
Ms Carpos’ death. The two care workers on shift with Ms Carpos on the evening 
of 25 December 2022 completed themed choking supervisions, and the Branch 
Manager also included reference to the expectations surrounding choking within 
the  branch  newsletter  and  sent  a  specific  email  to  care  workers  with  relevant 
information and a flashcard on choking.  

4.2.  More  widely  across  CCH  Group,  the  expectations  in  respect  of  choking, 
aspiration and swallowing difficulties were and are regularly included in bulletins 
that are sent to / shared with both operational teams and care staff. We currently 
use a number of different mechanisms to deliver bulletins – for example, emails to 
care and operational staff, team meetings and through our new CCH Connect 
app (discussed above at paragraph 2.10 and at paragraph 4.4.3).  

 
 
 
 
 
 
 
 4.3. 

CCH Group had also updated its induction and refresher training from October 
2022  (starting  with  the  induction  training  and  then  moving  to  the  refresher 
training)  to  include  more  detail  on  choking  and  aspiration.  This  version  of  the 
training was completed by the two care workers on shift on the evening on 25 
December 2022, in June and August 2023. Our training on choking and aspiration 
has  since  been  further  updated  and  launched  to  include  additional  clarity 
around aspiration (again, starting with the induction training and then moving to 
the refresher training, the updated version of which is due to go live this week).  I 
have  appended  a  printout  of  the  materials  from  the  most  recently  updated 
[induction / refresher] training at Appendix 2 to demonstrate the topics covered. 

4.4. 

In addition, following the Inquest in December 2023 and after reflecting on the 
Report  for  the  Prevention  of  Future  Deaths,  MiHomecare  and  CCH  Group  has 
made, and will make the following changes:  

4.4.1.  CCH  Group’s  Best  Practice  Forum  has  considered  the  circumstances 
surrounding Ms Carpos’ death as part of a serious incident review. A number of 
actions  have  been  prompted  by  this  review.  For  example,  the  themed 
supervision relating to choking (see paragraph 2.6) is being updated to include 
more detail on aspiration / aspiration pneumonia and the updated version is 
due to be released by the end of July. In addition, there is also a campaign 
initiative  that  has  been  created  to  highlight  both  choking  risks  and 
management  alongside  aspiration  and  the  differences  in  presentation.  This 
initiative is expected to be launched prior to the end of June 2024 and will be 
included on our new CCH Connect app as a ‘’Talking Head’ discussion, along 
with an updated prompt card for all staff. Please see the latest version of this 
updated prompt card at Appendix 1. Staff will be encouraged to review the 
initiative / prompt card via notifications in the app, and Branch Offices will be 
informed to tell staff about the initiative / card in team meetings. 

4.4.2.  Our care planning tools are also being reviewed and as a part of this extensive 
project, the risk management around difficulties with eating and drinking (and 
hence  the  risks  surrounding  aspiration)  will  be  considered.  This  project  is  still 
ongoing  (expected  to  be  concluded  before  the  end  of  summer),  but  it  is 
expected that one of the amendments made will be to ensure the tools include 
particular  reference  to  aspiration  rather  than  just  swallowing  difficulties  more 
generally.  

4.4.3.  As stated earlier we have our new CCH Connect app. This has just launched 
and  gives  us  the  opportunity  to  connect  with  our  teams  instantly  and  to 
highlight policy changes, learning initiatives and other group news. We have 
talked about some of the specific benefits / uses of this app above in this letter. 

5.  I  would  like  to  take  this  opportunity  to  express  my  sincere  condolences  to  Ms  Carpos’ 
family and friends. I understand she was very well regarded by those who cared for her 
and will be missed.  

 
 
 
 
 
 
 
 6.  Please do not hesitate to contact me should you have any questions.  

Yours Sincerely  

Chief Executive Officer 
City and County Healthcare Group