Anoush Summers

In the matter of a response to a prevention of future death report arising from 

the inquest into the death of Miss A. Summers. 

1.  This is the response to the Prevention of Future Death Report (PFDR) issued by 

HM Assistant Coroner Mr Bucket dated 6 June 2024, following his inquest of the 

same  date,  into  the  death  of  Miss  Anoush  Summers.  The  PFDR  is  a  public 

document. This response is provided to the Court as directed, by Supreme Care 

Services Ltd, the care provider. They are a domiciliary care agency who provided 

personal care to the deceased. 

2.  The care provider was made aware by the service user that her wrist pendant was 

not working. The service user had full capacity and was able to raise concerns and 

communicate her wishes.  

3.  The pendants have a testing mechanism where a service user can check to see if 

it is working. It is also understood that the third-party telecare provider (Livity Life), 

which  has  full  responsibility  for  the  provision  and  working  order  of  any  such 

pendant, including maintenance and repair, undertakes remote routine testing of 

devices of their own volition.  

4.  The telecare provider ought to have been aware that the pendant was not working 

through its own testing. 

5.  The  role  of  the  domiciliary  care  provider  was  not  to  supply,  maintain,  repair  or 

replace a faulty wrist pendant. No contractual arrangements or requirements were 

made to that effect. 

6.  It is understood that the telecare provider was not made an Interested Person in 
the inquest under section 47 of the Coroner’s and Justice Act 2009 and it would 

have been preferable given that they engage the threshold of sufficient interest, in 

the proceedings which focused on the pendant. 

1 

 
 
 
 
 
 
 
 
 7.  The pendant does not alert or summon the care provider. It is a direct link to the 

telecare provider. 

8.  The provision of the pendant arises from Livity Life care as the telecare provider. 

As  such,  it  is  incumbent  upon  them  to  supply,  routinely  monitor  and  replace 

pendants if they become faulty. The telecare provider was correctly informed by 

the  service  user  that  her  pendant  was  faulty.  The  service  user  was  capable  of 

reporting  this.  She  was  assisted  by  the  care  provider  in  doing  so  and  it  was 

reported immediately. 

9.  The care provider correctly recorded that the service user had concerns about her 

pendant not working on 6 January 2024. 

10. As was noted in open court, the witness statement of the local authority, Miss S 
Bristol, (paragraph 72), records “the service user was assisted by the carer with 

reporting  the  issue directly  to  the  telecare  company.  The  report of  a faulty  wrist 

alarm was received by the telecare company on 8 January 2024. Repairs by the 

telecare company are actioned within five working days, subject to being able to 

reach  the  named  contact  (three  attempts  are  usually  made  to  reach  the  name 

contact). Unfortunately, the company was unable to make contact with the next of 
kin until 14 January 24.” Although the statement says that the report was received 

by the telecare company on 8 January 2024, it was actually reported on 6 January 

2024.  

11. The statement also records, “the case notes and my own assessment show that 

Ann demonstrated capacity in relation to her decision-making about her care and 
support needs. As it was and wishes to remain her home, ASC facilitated  Ann’s 
wishes and provided her with support they were able to.” 

12. It  is  not  known  why  the  telecare  company  were  not  asked  or  did  not  provide 

evidence to the inquest regarding their role in the provision, testing, maintenance, 

repair  and  replacement  of  the  pendant,  as  well  as  their  inability  to  contact  the 

2 

 
 
 
 
 
 
 deceased within their own timeframes and what efforts they made. It is not known 

what they do in circumstances of non-contact. 

13. The apparent  agreed protocol  for  repairs,  which  is outside the  remit of the  care 

provider, shows there is an agreement in place with the commissioning authority 

and  the  telecare  provider,  as  to  timeframes.  Here,  there  is  a  five  working  day 

turnaround to replace pendants, unless it is urgent, when as it turns out, there is a 

service standard for it to be done within 2 working days. This has been found out 

subsequent to the inquest.  This appears to mean if a faulty pendant  notification 

falls over a weekend, the accepted response time as a minimum might be seven 

days. 

14. Once the information had been given to telecare provider it was incumbent upon 

them  to  make  contact  with  the  service  user,  her  family,  the  local  authority  who 

commissioned the pendant and indeed her care provider. No evidence appears to 

have been called as to why the telecare provider failed to make contact with the 

service  user  or  somebody  on  her  behalf.  It  is  not  known  what  they  did  with  the 

referral or why if they did attempt all reasonable telephone contact, they did not 

post a letter to the service user and/or contact the commissioning local authority. 

These are not matters of regulation by a care provider. The care provider does not 

subsume the responsibility of the telecare provider or commissioner. 

15. As a result of the issue surrounding the telecare provider, the care provider has 

reviewed all of its service users with pendants and engages in weekly testing of 

them. This is a robust approach and one not previously asked of them. 

16. It  remains  the  role  of  the  telecare  provider  to  monitor  and  replace  any  faulty 

pendants  within  the  terms  of  its  contractual  arrangements  with  the  funding 

authority and it is also their responsibility to routinely test pendants. 

17. As an abundance of caution, given the uncertainty surrounding the commissioning 

of telecare pendants and their role with the local authority, all faulty pendants are 

3 

 
 
 
 
 
 
 notified to the local authority so they can take primacy to act and ensure  that a 

repair or an alternative is commissioned. 

18. It is understood from the evidence heard, that the local authority said that it would 

have  commissioned  care  on  a  one-to-one,  twenty-four  hours  a  day  basis,    for 

service  users  in  the  situation  of  a  faulty  and  unrepaired  pendant.  This  was  not 

information  made  known  to  the  care  provider  nor  is  it  thought  that  it  would  be 

known to the telecare provider. Had it been the position, then the telecare provider 

would have, on being unable to make contact with the service user or anybody on 

her behalf, notified the local authority who would have put in place an enhanced 

care package. This issue arose post inquest and was requested but no one-to-one 

on a twenty-four hours a day care package was engaged. It is therefore relevant 

for  the  local  authority  to  inform  the  care  provider  of  action  to  be  taken  during 

knowledge of and or repair a faulty pendant. 

19. The responsible telecare provider, it is understood, continues to undertake remote 

testing of its devices to ensure that the equipment remains working, and any faults 

can be actioned. 

20. The livitylife.co.uk website says the following, “Our successful partnership with the 

London  Borough  of  Hackney  delivers  an 

Integrated  Telecare  Service 

encompassing  Call  Monitoring,  provision  of  a  24/7  Telecare  Response  Service, 

and  Telecare  Equipment  provision  including  supply,  installation,  maintenance, 

testing,  reprogramming  and  decommissioning  with  follow-up  visits  to  help  keep 
residents safe and independent home.” 

21. The hackney.gov.uk help at home website says that the service time frames are 

“Service timeframes 

TEL aims to: 

• 
• 

replace or repair any TEL equipment within 2 working days when the need is urgent 
replace or repair TEL equipment if needed, within 5 working days in non urgent 
circumstances 

4 

 
 
 
 
 
 Livity Life provides: 

•  TEL repairs and maintenance 
•  TEL emergency responders for Hackney 
•  monitoring alarm service 

To report an issue with your TEL equipment press the button on the wearable device or 
base unit to speak to the 24 hour Monitoring centre. If this is not possible, contact the 
emailing 
Haggerston 

calling 

based 

by 

or 

, 

team 
. 

Our council based TEL team: 

• 
review referrals 
•  order equipment 
•  provide advice 
•  work with Livity Life to coordinate TEL services 

22. It  does  not  denote  what  constitutes  urgent  and non-urgent provision  nor does  it 

note to contact the local authority separately. 

23. In the circumstances, a telecare pendant is provided by the telecare provider who 

is responsible for its provision, repairs, testing and maintenance as commissioned 

by the local authority.  

24. In  this  matter,  the  telecare  provider  was  informed  of  the  faulty  pendant  and  for 

reasons yet to be understood, did not contact the service user in any way, nor the 

local authority nor the care provider. 

25. As a result of concerns arising and to maintain high standards of care, the care 
provider has undertaken a review of all  service users’ pendants and undertakes 

weekly checks of them. It reports faults to the responsible telecare provider and 

commissioning  local  authority.  It  does  not  subsume  the  responsibility  of  the 

telecare provider nor the local authority in relation to this. 

26. Going  forwards,  it  is reasonable  to  expect  that  if  the  telecare  provider identifies 

faults during routine testing, that it contacts the care provider, service user (and/or 

their family) and the local authority so that measures can be put in place to mitigate 

5 

 
 
 
 
 
 
 against risk. It would also be helpful if the telecare provider and the local authority 

provided  clear  flowcharts  on  the  actions  that  should  be  taken  by  the  various 

stakeholders when equipment is found to be faulty. 

27. The  care provider  takes  service  user safety  very  seriously and  continues  to put 

service users first. 

  Supreme Care Services Ltd  

2 August 2024  

6

Quality : Safety - Innovation

Edwin Buckett
Assistant Coroner
Inner North London
Poplar Coroner’s Court
127 Poplar High Street
London

£14 0AE

24 July 2024

Dear Edwin Buckett,

lam writing in reference to the Regulation 28: Prevention of Future Deaths report for Anoush Summers
(died 14.1.2024), as enclosed.

For incidents involving Regulation 28 notices where Technology Enabled Care (TEC) has played a part in
any failures, whether through service or equipment, it is customary for the TEC Services Association
(TSA).to provide commentary as.the independent industry subject matter.expert.

About the TSA:

The TSA is the industry body committed to transforming the TEC sector by strengthening partnerships,
leveraging data, and empowering people, while addressing the demands, scope, and opportunities in
Technology Enabled Care.

We strive to ensure the quality and safety of TEC by setting and developing standards and providing
independent and trusted audit and certification through our wholly owned subsidiary, TEC Quality Ltd, an
accredited body by the United Kingdom Accreditation Service (UKAS).

We offer support and knowledge-sharing to members aiming to improve the delivery of TEC services,
grow their business, or enhance their impact on the TEC sector.

About TEC Quality:

TSA maintains a set of standards called the Quality Standards Framework (QSF), against which we audit
service providers through our certification body, TEC Quality Limited. This framework is designed to
minimise errors. We advocate for commissioners and procurement bodies to specify the QSF in tenders.
Although this scheme is votuntary, it is the only UKAS TEC accredited scheme in the sector.

The QSF is regularly reviewed to align with British and European standards, ensuring the TEC sector
provides current and robust TEC services and equipment.

The Service Delivery modules of the QSF cover Assessment and Reassessment, Installation and
Maintenance of TEC, TEC Monitoring, and TEC Responder Service. Additionally, there are 10 Common
Standards:

TEC Quality Ltd Suite 8, Wilmslow House, Grove Way, Wilmslow. SK9 SAG
Tel: 01625 520320 { Email: admin@TECQuality.org.uk | www.tecquality.org.uk | Twitter: @TSAvoice

e User and Carer Experience

e User and Service Safety

e Effectiveness of Service

e Information Governance

e Partnership Working and Integrated Services
e The Workforce

® Business Continuity

® Ethics

© Performance and Contract Management

® Continuous Improvement and Innovation

Our ISO 19011 trained auditors conduct on-site and virtual audits to ensure service providers have
processes in place for risk assessments, re-evaluation of service user needs, and timely installation,
repair, and maintenance of equipment.

Commissioners should recognise that assessing the need for TEC is an ongoing process requiring
appropriate funding and service provision, which is crucial for any TEC solution.

While Livity Life (the contracted TEC provider) is QSF Certified as a monitoring centre, the frontline
services provided for Hackney Council, such as TEC Assessment, Installation, Maintenance, and TEC

Response, are not.

In this case, it appears there were issues with the equipment provided and the response to these failures
by the commissioned TEC provider, as well as the safety and quality standards set by the commissioner
in the contract for Hackney Council. We believe there are lessons to be learnt and would appreciate the
opportunity to further investigate and provide comments to the Coroner, which will help prevent similar
incidents in the future.

The TSA continues to advocate for the QSF to be cited by commissioners and will work tirelessly to raise
awareness of the QSF's importance in ensuring the future safety of vulnerable individuals who rely on
TEC equipment to remain safe and independent in their homes.

A similar initiative to that of the NHS, driven by Coroners like yourself, Directors of Adult Social Care, and
the Home Office, should mandate that TEC services are verified for quality and safety through audit and
endorsement of the TSA Quality Standards Framework.

| look forward to your response.

Yours faithfully,

Head of Quality and Improvement
T :

TEC Quality Ltd Suite 3, Wilmslow House, Grove Way, Wilmslow. SK9 SAG
Tel: 01625 520320 | Email: admin@TECQuality.org.uk | www.tecquality.org.uk | Twitter: @TSAvoice

Regulation 28: Prevention of Future Deaths report

Anoush Summers (died 14.1.2024)

THIS REPORT IS BEING SENT TO:
(1)

Chief Executive ~

London Borough Hackney
Town Hall

Mare Street

London

E8 1EA

(2)
Director of Supreme Care Services Limited
9 Crown Parade
|\Morden
Surrey
SM4 5DA

CORONER

lam: Edwin Buckett
Assistant Coroner
Inner North London
Poplar Coroner's Court
127 Poplar High Street
London E14 0AE

CORONER'S LEGAL POWERS

| make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and

The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.

INVESTIGATION and INQUEST

On the 224 January 2024 Assistant Coroner Sarah Bourke began an
investigation into the death of Anoush Summers who died aged 77, on
the 14'" January 2024 at Homerton University Hospital, Homerton Row,
London, E9.

The investigation concluded at the end of the inquest on 6" June 2024
conducted by myself, Assistant Coroner Edwin Buckett.

| made a determination at inquest that the deceased died as a result of
hypothermia which resulted-from a fall at home following a long lie.

CIRCUMSTANCES OF THE DEATH

The narrative conclusion was as follows:

1. The deceased was a frail lady who was prone to falts. She lived
at home, alone, with carers who visited her twice a day. She had
a wrist alarm.
2. The wrist alarm was reported as broken and not working on the
6.1.2024, but it was not repaired or replaced.
. Sometime after 4.45pm on 11.1.2024, the deceased fell at

home. She was found the next day on the 12.1.2024 at 9am, by

a carer, wearing her wrist alarm and taken to hospital where she ~
died on 14.1.2024 of hypothermia.

. The absence of a working wrist alarm prevented her from being
found sooner that she was and probably contributed to her
death.

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.
Evidence was given that:

1. Although the wrist alarm had been reported as broken and not
working on the 6.1.2024, this was not replaced or repaired by the
company engaged by the local authority to provide this service
before the deceased fell at home between 11-12.1.2024.

. At the time the deceased fell, she was wearing her wrist alarm but
could not use it to summon help because it did not work.

. None of the carers who attended on the deceased after 6.1.2024
ensured that steps were taken to replace the wrist alarm or report
the matter to the local authority.

. The last carer who attended on the deceased before she died, on
the 11.1.2024, was not aware that the wrist alarm did not work as
she.had.not read the care notes. No clear instruction was given to
care workers about the extent to which they would be expected to
read the care notes relating to service users.

. None of the carers had been given.any training, instruction, or
guidance on the testing of wrist alarms to ensure they worked
properly when attending upon service users.

. There was no clear system identified between the company
providing carers and the local authority, as to the duties and
responsibilities of each in the reporting of faults with wrist alarms.

_lrely on all the above matters.

| am concerned that there is a risk of future deaths arising in
circumstances when vulnerable people, who live at home and are reliant
of wrist alarms which have been reported as not working, but have not
yet been repaired, may unable to summon help.

ACTION SHOULD BE TAKEN

In my opinion, action should be taken to prevent future deaths and |
believe that you and/or your organisation have the power to take such
action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date
of this report, namely by 2"4 August 2024. |, 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.

COPIES and PUBLICATION

| have sent a copy of my report to the following.

e HHJ Alexia Curran, the Chief Coroner of England & Wales

° EE. the daughter of Anoush Summers.

| am 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.

DATE 6.6.2024 SIGNED BY ASSISTANT
CORONER

Edwin Buckett