Peter Dickens

Dr Elizabeth Didcock 
Assistant Coroner 

2 July 2024 
Sent via email 

Dear Madam 

Thank you for your letter regarding the issuing of a Regulation 28 Report to Prevent 
Future Deaths at Cygnet Health Care. I will address each of the four areas identified 
within the report and update you on the actions that we have taken and any future 
actions  that  we  will  be  taking  to  ensure  the  risk  of  any  future  death  has  been 
minimised.  I am responding for Dr Romero as I am the Chief Executive Officer of the 
Social Care Division that was responsible for Mr Dickens’ care. 

A lot of work was undertaken at Beeches and more widely across Cygnet following 
Mr Dickens’ death. I apologise to you and Mr Dickens’ family that Cygnet staff were 
unable to give you sufficient reassurance at his inquest.   

Your first three matters of concern were as follows: 

a)  The persistent lack of compliance by staff with Eating and Drinking guidelines- 
there remains a lack of understanding by Beeches management of the reasons 
for the lack of compliance- if not understood, it is difficult to rectify in the future 
b)  The lack of recording of the specific strategies used at mealtimes when there 

is an Eating and Drinking guideline in place 

c)  The  Failure  of  management  and  the  Multidisciplinary  team  to  effectively 
monitor compliance with Eating and Drinking Guidance- I have no evidence 
before me that demonstrates improvement with this important issue  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Cygnet responds as follows: 

Beeches 

In January 2023 a new registered manager came into post at Beeches. Of the staff 
members  who  gave  witness  statements  to  the  police,  as  included  in  the  inquest 
bundle,  only  1  support  worker  still  works  at  Beeches  (in  addition  to  the  pre-existing 
deputy manager). There was no one consistent reason given in those statements as 
to why plans weren’t followed. It is therefore not possible for the registered manager 
to establish the reasons why the staff at the time did not follow Peter’s care plan and 
eating, drinking and swallowing (EDS) guidelines.  
The new manager has implemented a raft of measures since coming into post. He 
describes himself as having an extremely rigorous approach to eating, drinking and 
swallowing practices and prides himself on having built a safe space for staff to be 
open, honest and committed to self-development and improvement for the sake of 
residents at Beeches.  

New staff induction 

When  a  new  staff  member  starts  they  receive  a  one  week  induction  during  office 
hours  (Monday  to  Friday,  9am  to  5pm)  so  that  they  have  the  benefit  of  the 
management team being on site. They meet all of the residents, go through all of the 
care  plans  and  policies,  undertake  online  training  and  book  on  to  face  to  face 
training. If they are unable to complete their reading and show understanding of care 
plans, their induction is extended. Once induction is completed they then undertake 
two weeks on the rota with the team they are joining, shadowing shifts with, ideally, a 
residents’ key worker but otherwise, an experienced member of staff. Following this 
they have a formal meeting with a Team Leader who checks their confidence and 
competency.  They  then  have  a  monthly  supervision  session  during  a  6  month 
probation period.  

Agency staff must be pre-approved by the manager and they undergo an induction 
process.  They  are  then  allocated  to  work with  less  challenging  residents.  They  must 
read and understand the care plans of the residents they will be working with during 
the shift and whilst they are undertaking this, the activities coordinator will check the 
staffing  numbers  so  that  staff  numbers  are  not  reduced.  The  Team  Leader  then 
conducts regular checks throughout the day to ensure that the agency staff member 
of staff is competent and to provide support and answer any questions. The agency 
staff used do on the whole, know Beeches and the residents.   

 
 
 
 
 
 
 
 A  copy  of  the  choking/dysphagia  competency  assessment  and  supervision 
questionnaire is attached to this letter as Appendix 1. 

Spot questions 

When the manager is walking around the corridors, he regularly stops staff members 
and  asks  on  the  spot  questions  to  test  understanding  of  the  resident  they  are  with 
and/or of policies. This can be on any topic but during meals, it will be eating, drinking 
or swallowing related. The manager also undertakes a formal fortnightly walk around 
the entire unit and undertakes checks in all areas. This includes choking awareness 
monitoring. A copy of the walk around record is attached to this letter as Appendix 2.   

Spot checks 

In July 2023 the manager implemented Team Leader spot checks. Twice during the 
day shift and once during the night shift, Team Leaders undertake spot checks. On 
the day shift, at least one Team Leader has to be around for the eating and drinking 
at  meal  times  and  the  second  tends  to  focus  on  how  staff  are  interacting  with 
residents. The night check is always at dinner or breakfast. The Team Leader focuses 
on a member of staff, observes them and records aspects of the check. For example, 
a meal time check would include what food was eaten, how it was cut, whether it 
was prepared correctly and that a staff members was present. Any issues are reported 
back to the manager. The spot checks are discussed every Monday in the morning 
meeting. A copy of the spot check template is attached to this letter as Appendix 3.  

Weekly guidance checklist 

Following  Peter’s  inquest,  in  March  2024  the  manager  implemented  a  weekly 
guidance checklist. This involves a minimum of two weekly guidance checks, one of 
which is always on EDS. The manager, or in his absence the deputy manager, observes 
a  mealtime  and  makes  sure  that  the  EDS  guideline  is  followed,  that  the  staff 
understand it and ask questions of the staff to ensure they know what they are doing 
and  the  reasons  whys.  If  there  are  any  concerns  or  the  manager  wants  to  check 
anything, for example that the guidelines are still current and accurate, he raises this 
with  the  Speech  and  Language  Therapist  (SLT)  Team.  A  copy  of  the  checklist  is 
attached to this letter as Appendix 4. 

 
 
 
 
 
 
 
 
 
 
 
 Multi-Disciplinary Team (MDT) visibility  

The manager has also implemented a “meet the MDT” initiative. Each member of the 
MDT  has  provided  an  information  sheet  which  includes  “my  name  is”,  “my  job  is”, 
when  they  were  at  the  Beeches,  which  includes  how  to  contact  them  and  other 
information about them and their role. These sheets are displayed on a notice board 
in the link corridor between the main block and the residential block. It also includes 
information for staff on what to do if guidelines are not being followed and provides 
details  so  that  staff  can  contact  members  of  the  MDT  directly.  This  has  improved 
visibility, strengthened staff relationship with the MDT and fostered an approachable 
and collaborative environment. A photograph of this board is attached to this letter 
as Appendix 5.   

The manager also gave a presentation to the Corporate Safety Response Group on 
learning from Peter’s inquest and detailed the initiatives which are set out in this letter. 
A copy of that presentation is attached as Appendix 6.  

Choking board in main corridor 

There  is  a  large  board  in  the  main  corridor  displaying  choking  risk  and  awareness 
posters. Copies of those posters are attached as Appendix 7.   

Monthly theme boards  

In  March  2023  the  manager  implemented  an  initiative  to  raise  competency  and 
refresh  knowledge.  A  large  notice  board  is  displayed  in  the  main  corridor  in  the 
residential unit. A topic is chosen each month and the board has a range of resources 
on it pulled from the Cygnet intranet, CQC and the Local Authority.  

The  April  2024  topic  was  eating  and  drinking  following  Peter’s  inquest  (photograph 
attached as Appendix 8) and the June topic was lessons learned, how to mitigate the 
risks and why (photograph attached as Appendix 9).  

At end of each month there is a knowledge test on that month’s topic. The results are 
scored  and  put  into  graphs  and  a  team  percentage  reached.  If  a  staff  member’s 
score is low, an action plan is developed. This could be a team meeting agenda item, 
retraining, or something else (for example flashcards with QR codes for reporting were 
developed following the safeguarding topic and questionnaire scores). There is then 

 
 
 
 
 
 
 
 
 
 
 a write up of that month’s topic. The write ups for April and June 2024 are attached 
as Appendices 10 and 11.  

EDS guidelines and auditing 

EDS guidelines are located in each resident’s care file in the duty office, in the main 
kitchen with the chefs and in the therapy kitchens. There are currently two residents in 
each  of  the  two  Beeches  units  who  have  EDS  guidelines.  Compliance  with  EDS 
guidelines is audited by the SLT Team.  

Datix incident reporting 

The  manager  has  improved  and  increased  incident  reporting  protocols  so  that  he 
and the wider staffing group has an improved awareness of these matters. 

Management handover  

Each shift leader completes and sends a handover to the manager, deputy manager 
and team leaders. This covers things such as resident health, PRN required, any issues 
and meal times (its content could vary from shift to shift). As well as documenting ever 
resident,  it  also  captures  staffing.  A  copy  of  the  management  handover  form  is 
attached as Appendix 12. 

Fortnightly triangulation analysis 

The manager undertakes a fortnightly triangulation analysis whereby he reviews Datix 
(the incident reporting system), Pink Notes and handovers. He will pick a resident at 
random and go through the Pink Notes to check that entries are sufficiently detailed, 
correct and activities recorded. He will then look to see if any incidents are recorded 
on  Datix  and  that  these  are  cross-referenced  between  the  two  systems  and  on 
handovers. A copy of the triangulation analysis form is attached as Appendix 13.  

Cygnet  

Training 

Dysphagia and Choking Awareness training is part of the annual mandatory training 
and additional training can and is sourced from the SLTs as and when required.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Audits 

The SLT team are conducting audits of Cygnet’s EDS guidelines at set time intervals. 
The  outcomes  of  these  audits  are  discussed  with  managers  and  presented  at  our 
Clinical Audit Committee for wider discussion and learning.  

Choking vests 

Research suggests that most people don’t deliver back slaps effectively. The Director 
of Nursing has therefore ordered two further choking vests which will be trialled on two 
sites for a period of 1 month and if successful will be rolled out across every site within 
Cygnet. At the Lessons Learned meeting in June 2024 a commitment was made to 
ensure that sites which already have vests utilise them as part of life support training.  

Awareness 

Each  year  there  is  a  nutrition  and  hydration  week  across  Cygnet  and  we  take  the 
opportunity to raise the profile of choking and its prevention and treatment. The week 
also includes a national swallowing awareness day. We ran this campaign in March 
2022,  2023  and  2024.  During  these  weeks,  we  shared  a  series  of  blogs,  posters  and 
resources.  Services  were  also  supported  to  refresh  their  knowledge  of  critical 
documentation  such  as  our  Choking  Risk  Screening  Assessment  Tool.  We  are  also 
running a corporate choking awareness campaign in September 2024. This will see a 
range  of  educational  and  promotional  materials  relating  to  choking  risk  being 
delivered across the coming months.  

In March 2022, we also hosted a learning lessons conference, and Choking Risks and 
Dysphagia were an agenda item.  

Serious incidents 

The  Director  of  Nursing  chairs  a  complex  case  panel  which  reviews  all  incidents 
graded as moderate harm and above. Incidents of choking recorded on our incident 
reporting system (Datix) that reach this threshold are discussed. This is a very important 
panel  to  review  incidents  and  identify  any  learning  opportunities  that  can  be 
explored. Under the new incident reporting framework (PSIRF), if incidents of choking 
are  identified,  there  will  be  system-based  thematic  reviews  which will  look to  see  if 
there are any common themes and wider learning.  

 
 
 
 
 
 
 
 
 
 
 
 There  is  also  a  monthly  lessons  learnt  meeting  where  we  identify  any  themes  from 
incidents  and  any  associated  learning.  Following  this  a  learning  bulletin  is  shared 
across all sites within the organisation.  

The  Director  of  Nursing  also  reports  choking  incidents  and  any  areas  requiring 
improvement at Executive Board meetings. 

Your fourth concern was as follows: 

d) Apparent failure to provide the level of support that was funded for Peter the 
costings and support level were set out in his current care and support plan- 
the Beeches management team appeared unaware that he was funded for a 
total of 18 hours per day, which is broken down into 12 hours one to one support 
per day and 6 hours two to one support per day 

At the time Mr Dickens choked, he was receiving the support that he was funded to 
receive.  For  residents  with  complex  needs  and  levels  of  support  and  staffing  that 
changes  throughout  the  day,  funding  is  not  straight  forward  and  would  require  a 
deep dive into the contracting, commissioning and actual staff provision. A witness 
giving  evidence  over  2  years  after  the  death  of  a  resident  would  not  be  able  to 
accurately recall the arrangements that were contracted and  what was delivered 
when.  

I  do  hope  that  this  letter  has  provided  you  with  a  level  of  assurance  following  the 
tragic death of Mr Dickens. As an organisation we have taken a number of actions 
locally and across the Cygnet Group and continue to keep these under review. Any 
new operating guidance emerging from NICE or the Royal Colleges, will also remain 
under review and will be at the heart of best practice in relation to this area.  

Yours sincerely 

Chief Executive Officer 
Cygnet Social Care