Richard Fitzgerald

MISS N PERSAUD 
HIS MAJESTY'S CORONER 
East London Walthamstow Coroner's Court, 
Queens Road  
Walthamstow, E17 8QP 

30th July 2024.  

Dear Ms Persaud,  

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS  

This  is  Gable  Court’s  response  to  your  report  made  under  paragraph  7,  Schedule  5,  of  the 
Coroners  and  Justice  Act  2009  and  Regulations  28  and  29  of  the  Coroners  (Investigations) 
Regulations 2013, dated 10 July 2024, following the tragic death of Richard Fitzgerald on 26th June 
2023.  

Thank you for your conduct of the inquest and for your identification of a number of matters of 
concern, which are set out in the Report.  

Richards tragic death has had a profound effect on the whole team and our deepest condolences 
go out to Richard’s family.  

Richard had resided at Gable Court for eight months and during his initial placement, when he 
was able to communicate his needs, he expressed that he was very happy with his placement at 
Gable Court. He had formed many positive relations with his fellow residents, also many staff 
had a very positive relationship with Richard, and they were extremely fond of Richard. Sadly, his 
condition deteriorated, and it became more difficult for Richard to express his needs effectively 
and  it  became  more  and  more  challenging  for  him.  Richard  remains  very  much  deep  in  our 
thoughts.  

As an organisation we will strive in every way to prevent this from happening again.  

Action Gable Court took immediately following the incident.  

1.  Further First aid including Basic life support training has been delivered in house to all 

staff. 

2.  Further Dysphasia, Dysphagia and IDDIS training has been delivered in house to all staff. 
(Since the incident, Gable  court staff have had several  training sessions on Dysphasia 
and IDDIS to ensure all staff understand signs and symptoms and know when to escalate 
any concerns promptly, and to ensure all staff are equipped with the full knowledge and 
are competent as well a confident in an emergency situation.  

3.  The Swallowing policy has been reviewed and updated. This has been disseminated to all 
staff and has been discussed at team meetings and at the daily flash meeting regularly.  

 
 
 
 
 
 
 
 
 4.  Staff are briefed daily at handovers on the importance of any high-risk residents.  

5.  Grab files have been re-issued to all the units.  

6.  Choking risk assessments have been completed on admission and reviewed monthly for 
all  residents  living  at  Gable  Court,  as  well  as  when  instructed  to  do  so  by  external 
professionals or after incidents. 

7.  A new Clinical support manager has been appointed that is highly experienced to support 

the home manager.  

8.  The protocol for the safety of the food trolley has been reviewed. The trolley is not left 

unattended at any time unless it is in a locked room.  

Further improvements we made prior to the hearing on 1st July ’24 to mitigate future incidents:  

1.  A SALT register has been developed and shared with kitchen, including all IDDIS Levels.  
2.  An Escalation to signpost the management team and leadership team at Gable Court, in partic-
ular if they are experiencing challenges with any resident in providing safe care. This includes 
which professionals should be contacted and involved in the resident’s care review.  This also 
includes a risk management plan to support the home in minimising the risk of deterioration in 
the resident’s physical and mental wellbeing.  

3.  An extra member of staff has been allocated to the ground  floor; they  will be present during 

mealtimes to oversee the safety of high-risk residents.  

4.  Ensure that all care plans are being followed and monitoring this, ensuring that difficulties in 
following care plans due to Residents’ behaviours are fed back to external professionals so that 
these can be adapted to ensure the Residents are safe and their needs are being met. 

5.  A Clinical Lead/Unit Manager was appointed to oversee any clinical concerns in all units, care 

plans, risk assessments and to support staff with all clinical work aspects. 

6.  Care plans and risk assessments are now more robust and improved to meet individuals care 

needs. 

7.  Care plan training both online and face to face has taken place. 
8.  Gable court to keep the local authorities informed of any changes in resident’s care needs. 
9.  The Pre-admission assessment has been reviewed in ways that Gable court assess new resi-
dents to ensure that we can fully meet their care needs before admission, especially around 
challenging behaviour and appropriateness of the environment.  

Matter of concern 1  

The Care Home staff were aware that the SALT care plan could not be consistently followed in 
terms  of  close  supervision,  but  dld  not  discuss  this  with  the  SALT  team  to  ensure  that  a 
contingency care plan could be put into place. 

Further action that has been taken since the Inquest 

•  The  Senior  management  team,  alongside  a  specialist  Independent  Consultancy  team 
have reviewed every resident care needs, with swallowing difficulties. They have ensured 

 
 
 
 
 
 
 
  
 that  a  robust  risk  assessment  is  in  place,  that  specifically  captures  any  barriers  in 
providing the care that SALT have prescribed. This piece of work has been completed.  

•  Meetings  are  taking  place  with  the  whole  staff  team,  to  share  the  findings  from  the 
Inquest.  These  have  been  transparent  and  used  as  a  learning  opportunity  for  staff  to 
understand,  the  importance  of  escalating  concerns  back  to  the  practitioners  that 
prescribed  the  resident’s  care.  These  meetings  will  continue  over  the  next  couple  of 
weeks, until all staff have been shared lessons learnt. We anticipate that we should have 
met with all the staff by the end of July ’24.  

•  Clinical review meetings that take place are specifically capturing any difficulties staff are 
experiencing in delivering safe, effective care and these will be triggered for a re-referral 
to the relevant professionals. This is an on-going piece of work.  

On-going learning 

•  Clinical  review  meetings  will  take  place  every  2  weeks  that  will  identify  all  high-risk 
residents and pick up on any barriers in delivering safe/ effective care. If any concerns are 
noted these  will be escalated  to  the relevant professional team as well as  the funding 
authority.  

•  The home has a clinical support manager, and alongside the manager they will oversee 

all high- risk residents on-going care needs.  

•  The  Clinical  lead  /  or  home  manager  will  ensure  they  are  in  attendance  of  any  SALT 
assessments / reviews. If they are not available then it will always be a qualified nurse of 
senior carer that attends the review, to ensure any changes are flagged immediately to 
the SALT team.  

Matter of concern 2 

The risk of  Mr Fitzgerald picking up food  was known to  staff but was not incorporated into  the 
choking risk assessment and risk management plan.  

•  As mentioned above the SMT alongside an Independent Consultancy team have reviewed 

all the choking risk assessments, specifically capturing any associated risks.  

•  The Clinical support manager has met with the senior teams, including nurses, seniors’ 
carers and clinical lead clarifying the importance of capturing all the associated risks.  

•  We will meet with the whole team and share the findings from this report and go through 
the  risk  assessment  process,  highlighting  the 
importance  of  staff  raising,  and 
documenting all incidents and any concerns with residents. We will complete this by the 
end of July’ 24.  

On-going learning  

•  Clinical  review  meetings  will  take  place  every  2  weeks  that  will  identify  all  high-risk 
residents and if any risks are identified. The manager will then ensure, that they allocate 
the relevant staff member to update any risk assessments and that will be reviewed by 
the home manager.  

 
 
 
 •  The home manager will update her daily report to the RI and the Quality and Compliance 
Manager,  the  Quality  &  Compliance  Manager  will  then  audit  that  care  plan  and  risk 
assessment.  

Matter of concern 3  

The  emergency  protocol  for  choking  was  not  followed  by  staff  in  attendance  on  24  July  2023 
(including qualified nursing staff)  

•  Emergency response training , including First aid and Basic life support training has been 
delivered  to  all  staff,  specifically  focusing  on  choking  incidents.  This  training  also 
included –Basic life support this was delivered on 10th July ’24.  

•  We have made referrals to the NMC for both the qualified staff. One of those staff resigned 
from her position due to personal reasons. The other member of staff is on bank following 
their return from maternity leave and we are not currently using her on our bank. A further 
investigation is taking place and should be completed and concluded by mid - August.  

•  We have received a decision from NMC in regard to the two referrals that were submitted.  

•  Nurse  EO  they  have  concluded  that  there  are  Regulatory  concerns  that  they  will  be 
investigating  further  under  RC1:  “Failure  to  respond  appropriately  to  a  deteriorating 
patient – in that you neglected to provide the necessary care to Resident A when you knew 
he was deteriorating” 

•  Nurse  SA  they  have  considered  the  fitness  to  practise  concern  raised  and  they  have 

decided we won’t be investigating it further at this time. 

On going learning  

•  Regular workshops will take place to further embed all the learning from the training that 
has been delivered; this will include how to deal with practical situations. This will further 
empower staff and give them more confidence in dealing with emergency situations.  

•  Visible posters are available for staff throughout the building. 

•  Grab  files  that  include  how  to  deal  /  respond  in  certain  situations  will  be  regularly 

discussed / shared at team meetings.  

•  We  have liaised with our colleagues from SALT to seek their advice on the use of anti-
choking  devices.  If  they  feel  that  it  would  benefit  our  service,  then  we  will  source 
appropriate devices and arrange training on the use of these.  

 
 
 
 
 
 
 
 
 Matter of concern 4  

The Care Homes investigation lacked thoroughness and professional curiosity.  

• 

It was very  clear  from  receiving the  updated  bundle,  that  the situation on the day  was 
chaotic.  

•  The  senior  manager  that  led  on  the  investigation,  is  no  longer  in  post  she  left  in  late 

October ’23. 

•  The Home Manager is also no longer with the organisation 

•  We have appointed a Consultancy Care Company to support the team at Gable Court, 

whilst we appoint a suitable new Home Manger.  

On-going learning  

•  Following  any  significant  events,  the  investigation  will  be  allocated  to  at  least  two 
independent  investigators,  not  from  the  Care  Home  involved  in  the  incident.  This  has 
been implemented immediately.  

• 

If there are not two Senior Managers available from the group, consideration will be given 
to  outsource  the  investigation  to  an  independent  person  not  from  our  group.  This  has 
been implemented immediately.  

•  Once  a  thorough  investigation  has been  completed,  this  will be presented and  further 
scrutinised by at least two members of the Board of Directors, to satisfy themselves that 
a  thorough  and  robust  investigation  has  taken  place.  This  has  been  implemented 
immediately.  

•  Training  is  being  sourced  for  the  Senior  Management  team  on  preparing  for  Coroners 
inquests, this will further support them in being more thorough in their Investigation skills. 
This will be completed throughout September.  

Once again, we would like to take the opportunity to thank you for highlighting these matters of 
concern, and for giving us the opportunity to respond. We will continue to work with SALT and the 
Local Authority to make sure we have robust risk assessments and care plans in delivering safe 
effective care to vulnerable people with swallowing difficulties who are at risk of choking.  

Yours sincerely