James Capstick

Care Quality Commission
Citygate

Gallowgate

Newcastle upon Tyne
NE1 4PA

Telephone:

www.cqc.org.uk

Kally Cheema LLB
HM Senior Coroner

Cc: Dr Nicholas Shaw

31 October 2024

Our Reference [nn
Your Reference: EE

Dear HM Senior Coroner Kally Cheema and Assistant Coroner Dr Nicholas Shaw,

Regulation 28 Prevention of Future Deaths Report following Inquest into the
death of James Reginald CAPSTICK.

Thank you for sending Care Quality Commission (CQC) a copy of the prevention of
future deaths report issued following the sad death of James Reginald Capstick.

We note the legal requirement upon CQC to respond to the report within 56 days, that
being by 27 September 2024, and would like to thank you for agreeing to our request
for an extension until 04 November 2024.

We are grateful for the details provided in your report and confirmation of the outcome
following inquest.

With regards your query in relation to CQC making further enquiries, we have taken
action as outlined below.

CQC were informed of the outcome of the local authority safeguarding investigation
into the use of CPR on 1 December 2021 including actions to be taken to prevent
further incidents. Actions included internal investigation by the provider, audit of the
incident, a refresher of basic life support training for all staff, and a referral to the NMC
regarding the individual nurse’s conduct. CQC followed up these actions and were
reassured that staff had received refresher training in basic life support and that the
provider had taken appropriate actions in relation to the registered nurse involved in
the incident.

On 30 September 2022 CQC were notified of an allegation of abuse made by
ambulance staff relating to concerns of neglect in relation to Mr Capstick whilst a
resident at Westmorland Court Residential and Nursing Home. The concerns were
identified by ambulance staff on 13 September 2022 when called to transport Mr
Capstick to hospital. CQC are in the process of reviewing information related to this

safeguarding alert and are undertaking further enquiries to assess whether any further
regulatory activity should be considered.

Following receipt of notification of the death of Mr Capstick a targeted inspection was
carried out on 13 October 2022. This provided assurance regarding the safety of other
service users at the location.

We have given careful consideration to the concerns raised in relation to whether it
should be a requirement for care homes to have a defibrillator however this falls
outside of the role and remit of CQC. We should clarify that the role and remit of CQC
does not extend to prescribing how providers must meet the regulations stipulated, we
place the onus and responsibility on providers themselves to make decisions around
how best to deliver care safely and assure us of the same. There is no legal
requirement for care homes to install equipment such as defibrillators but if they were
to do so then there would be an expectation that staff are appropriately trained in how
to use such equipment safely. Where equipment such as defibrillators are not installed,
we would expect a provider to be able to demonstrate that they have suitable policies
and procedures in place to ensure appropriate resuscitation methods can be carried
out if required by suitably trained staff.

We hope this response provides sufficient information on the matters raised. Should
you require any further information from CQC then please do not hesitate to contact
us.

Yours sincerel

Interim Operations Manager

From the Acting Chief Executive and Registrar

ANAC

Nursing &
Midwifery
Council

Kally Cheema
Senior Coroner
HM Coroner
Fairfield
Station Road
Cockermouth
Cumbria

CA13 9PT

Ref no: i’
26 September 2024
Dear Ms Cheema

James Reginald Capstick - NMC response to Regulation 28 Prevention of
Future Deaths Report

Thank you for sending your Regulation 28 Prevention of Future Deaths Report (PFD)
in connection with the death of James Capstick for us to review in accordance with
paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28
and 29 of the Coroners (Investigations) Regulations 2013. | write to provide a
response on behalf of the Nursing and Midwifery Council (NMC).

| am very sorry to hear about the circumstances leading to Mr Capstick’s death and
I'd like to begin by offering my sincere condolences to his family for their loss. |
would like to assure you that we take concerns shared with us very seriously.

We have used the information in the PFD to reflect on the action we can take to
address the concerns you have identified and to make sure they do not occur again
where we have the power to do so. We set out below the action we have taken to
ensure that the professionals on our register are fit to practise safely and
professionally and that the public is protected in line with our role.

Your concerns

Your investigation into Mr Capstick’s death concluded that on 1 December 2021
Mr Capstick received CPR when not actually in cardiac arrest and as a result he
sustained a major chest injury which required a period of hospitalisation. This
massive chest injury led to respiratory insufficiency and an episode of pneumonia

23 Portland Place, London W1B 1PZ

020 7637 7181

www.nmce.org.uk

We're the independent regulator for nurses ancl miclwives in the UK, and nursing associates in England

Our vision 1s safe, effective and kind nursing and midwifery practice that improves everyone's health and wellbeing.

Registered charity in England ond Wales (1091444) and in Scotland (SCO38562)

which was treated successfully, however the combination of injury and illness led in
turn to his death on 1 October 2022.

We understand that you heard that three safeguarding referrals were made in
connection with the care provided to Mr Capstick. These related to:

1. concerns raised by the ambulance crew when Mr Capstick was admitted to
hospital having sustained a major chest injury;

2. concerns raised by friends who visited Mr Capstick at Westmorland Court in
early 2022 about the quality of care given to Mr Capstick;

3. further concerns raised by the ambulance crew about Mr Capstick’s
appearance in September 2022 when he was admitted to the Royal Lancaster
Infirmary.

We have noted that you heard the first two referrals were closed by social services,
and the third referral remains open.

In addition to the above, a General Practitioner gave evidence raising concerns
about the care being provided to residents at Westmorland Court. He said that care
had improved since Mr Capstick’s death, but he has to visit regularly to check
residents. There is a specific concern about entries made in Mr Capstick’s notes as
there was clear evidence that examinations entered in the notes were made at times
when this was impossible because he was in hospital.

A concern was raised about the absence of a defibrillator in the home at the time of
the incident. It appears one has now been installed.

Finally, you have raised with us specifically the concern about the registered nurse in
charge of the home on the night of Mr Capstick’s injury. There was a statement
which said the nurse forgot their basic training and was confused about what to do.
Basic checks and signs of life were ignored. You were told that a referral to us had
been made and acknowledged and have asked us whether the referral has been
closed.

Our role

The NMC is the independent regulator of more than 808,000 nurses and midwives in
the UK and nursing associates in England. We're here to protect the public by
upholding high professional nursing and midwifery standards, which the public has a
right to expect. We maintain the integrity of the register of those eligible to practise
and we investigate concerns about professionals. Our Code of Conduct contains the
professional standards that registered nurses, midwives and nursing associates

must uphold. We will investigate alleged breaches of the Code when we become
aware of them under our fitness to practise process.

We have two clear aims for fitness to practise:

a. a professional culture that values equality, diversity and inclusion, and
prioritises openness and learning in the interests of public safety, and

b. nurses, midwives and nursing associates who are fit to practise safely and
professionally.

In appropriate circumstances we enforce the standards set out in the Code through
fitness to practise proceedings. Fitness to practise proceedings can result in a range
of outcomes, ranging from the provision of advice to the registrant by the NMC to
removal from the register.

Our response to the concerns raised

We can confirm that our investigations in relation to the concerns raised about the
registered nurse in charge of the home on the night of Mr Capstick’s injury are
ongoing. We have shared your concerns as set out in the PFD with the investigating

ed VW

We have also considered whether the PFD raises any other concerns which we
need to act on. We have noted that concerns were raised about the care provided to
Mr Capstick generally at Westmorland Court and a specific issue relating to
inaccurate entries made within healthcare records. We have noted that at the time of
the inquest one safeguarding referral remained open.

In relation to this we have passed this information on to our Employer Link Service
(ELS) and to the New Referrals team to make enquiries in relation to these
concerns. We will investigate any concerns which fall within our remit through our
fitness to practise processes and share information with other organisations if
necessary.

Finally, we recognise that our processes can be very difficult for the friends and
families of patients who are connected to our investigations. We have a Public
Support Service (PSS) to help support people through the process and understand
how the investigation process works. Through it, our public support officers can
answer individual questions or provide one-to-one meetings and help explain the
different decisions that could be made. More information about our PSS can be
found here NMC public support service - The Nursing and Midwifery Council. We
have referred this case to the PSS team who will reach out to Mr Capstick’s family. |
am sorry that this has not been actioned until now.

Conclusion

Thank you for raising your concerns with us. | trust that our response sets out the
action that we are taking as a result of the concerns raised to improve public health,
welfare and safety. If you would like any further information or have any further
questions concerning this case or the steps we are taking, please do not hesitate to
contact us. Finally, | would like to again offer my heartfelt condolences to Mr
Capstick’s family.

Yours sincerely

Acting Chief Executive and Registrar

Wesimorland Court, High Knott Road, Arnside, Via Carnforth, LAS OAW aS
Telephone: 01524 761291 =| Ve
Fax: 01524 762640
Email: Manager@westmorlandcourt.co.uk

Dr Nicholas Shaw

HM Assistant Coroner for Cumbria
Fairfield

Station Road

Cockermouth

Cumbria

CA13 9PT

Case reference: EEE Re Inquest touching the death of Mr James Reginald Capstick
26 September 2024

Dear Sir

Westmorland Court Nursing and Residential Home provides the following response to the
Regulation 28 Prevention of Future Death Report issued by HM Assistant Coroner, Dr
Nicholas Shaw.

As was identified within live evidence during the inquest, a number of improvements had
taken place by the time of the inquest and since the sad death of Mr James Reginald (“Reg”)
Capstick. Improvements have been further and embedded in the intervening period
between the Inquest conclusion and the date of this letter. This letter seeks to set out those
improvements in care quality for the attention of the Coroner and provides a formal
response to those concerns.

Quality Improvement Plan

One of the key components to the improvement in the quality of our care has been the use
of the quality improvement programme. A Quality Improvement Plan (“QIP”) was in place
in conjunction with Lancashire South Cumbria ICB (“ICB”) and Westmorland and Furness
Council from 1 May 2024.

The QIP and ongoing monitoring process consisted of regular meetings with colleagues from
the ICB and Westmorland and Furness County Council. The purpose of the meetings was to

Company number: 4009674

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Westmorland Court, High Knott Road, Arnside, Via Carnforth, LAS OAW
Telephone: 02524 761291
Fax: 01524 762640
Email: Manager@westmorlandcouri.co.uk

assess our improvements and compliance with the QIP, to obtain updates from quality
colleagues including the CQC.

By way of update to the Coroner, the QIP identified that the following improvements/
actions were in place and ongoing at the meeting held on 24 July 2024. The meeting held on
23 September 2024, marked the conclusion of our meetings. The ICB and Westmorland and
Furness Council recognised the significant improvements observed following their visit to
the care home on September 3, 2024, Furthermore, they acknowledged the improvements
in both the quality and content of the care plans. We are currently awaiting the minutes
from this meeting.

A new role of Deputy Manager was created to increase resilience, review of the
workforce culture, and generally ensuring a high level of service within the home.
The Deputy Manager also supports with ongoing governance, management and
running of the Home. The Deputy Manager has been in post since the 30th of July
2024.

An external consultant has been reviewing the Home’s training matrix with the
Registered Manager and recommended some adaptations including adding a clear
training due date to ensure staff are pro-actively allocated to training courses on an
ongoing basis. These recommendations have been accepted and completed.

Health and safety audits have been completed independently and no asbestos or
structural issues have been noted, Four staff have been enrolled on level 4 food
hygiene. A COSSH folder is in place with an additional risk assessment and a
legionella survey was completed last year with no concerns raised. Furthermore, fire
risk assessments have been updated.

The Registered Manager has enrolled staff with “Skills for Care” so they can attend
further person-centred care planning training.

There has been a change in the way care plans are being written, with the intention
of making them more person centred, to ensure that members of care staff are able
to better proactively consider health concerns or any deterioration in health.

Company number: 4009674

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Westmorland Court, High Knott Road, Arnside, Via Carnforth, LAS OAW

Fax: 01524 762640
Email: Manager@wesimorlandcourt.co.uk

¢ A Home “Newsletter”, WhatsApp group and Facebook pages are in place and

working well to assist in smoother communication within the staff group and/ or
dissemination of updated guidance/ policies; and/ or engaging family and friends to
enhance communications between home and family/ friends; greater involvement of
residents re person-centred care and celebrating their activities. The CQC has
provided guidance regarding consent and the need for a social media policy which is
ongoing.

A family survey has been sent out and feedback has been obtained — please see
further comments below about the positive feedback obtained and the compliments
log.

The Clinical Lead has enrolled and currently undertaking the NVQ Level 5 in
Leadership and Management course.

The Community Mental Health Team has provided challenging behaviour training to
staff.

There have been good improvements noted by the ICB following submission of the
IPC audit.

A range of environmental matters have been attended to: The dishwasher is now
working and the fly zapper has been fixed; there are new stair and corridor carpets
now in place which is further evidence of the comprehensive audits/ assessments of
and actions taken to embed improvements into the home environment; a new fridge
has been bought and is in place; work has been completed on the roof; more than 12
rooms and corridors are being updated; the top floor has been completely
refurbished; some windows have been replaced; there has been the installation of 3
brand new boilers with one more to be changed; the Home’s lift has been upgraded;
a new fire alarm system is in place; and the staff room and some other areas of the
Home have been refurbished.

Two hourly UCR information is now discussed at staff handover to ensure staff

confidence in utilising the service and that any changes in a person’s health
Company number: 4009674

“19. fe , i, ,

Westmorland Court, High Knott Road, Arnside, Via Carnforth, LAS OAW
Telephone: 01524 761291
Fax: 01524 762640
Email: Manager@westmorlandcourt.co.uk

presentation is appropriately handed over to staff and that there is a continued drive
to sustain and embed improvement to care quality.

° Provider led audit and checks are now being completed and clearly documented to
ensure that there is suitable oversight in respect of care quality and to maintain
ongoing provider assurance of good governance of the service.

Compliments log

The improvements in relation to care quality have been feedback to the Home by relatives
and residents. A range of very positive comments are included within the compliments log
from August/ September 2024 — please see attached document (Appendix 1).

Lessons learned

As a Home, we are keen to drive “lessons learned” improvements across our care quality
and practice. Ongoing discussions have been taking place and have been had with all staff
about the case and understandably the concerns outlined by the Coroner in relation to basic
life support and accuracy of record keeping. All senior staff and registered nurses now have
the appropriate training in place for basic life support.

DNAR’s are now located on the inside front page of the resident files for ease of access,
which they were not prior to regulation 28. All staff have access to a safety checklist which
details which residents have DNAR’s, allergies, cognitive impairments and other pivotal
information.

Daily walk round audits are conducted which include testing staffs’ knowledge of the ABCDE
assessment process to competently assess a resident and identify whether a person is in
cardiac arrest.

Monthly mattress audits are in place and staff now have increased awareness and

understanding of the importance of checking the air-flow mattresses after each intervention
for those that are using air-flow mattresses.

Company number: 4009674

Westmorland Court, High Knott Road, Arnside, Via Carnforth, LAS OAW
Telephone: 01524 761291
Fax: 01524 762640
Email: Manager@westmorlandcourt.co.uk

We have implemented safety huddles with staff daily to improve resident safety and care.
The safety huddles will improve situational awareness, create an environment where staff
feel safe to raise concerns and integrate information to develop a comprehensive picture of
the status of residents in our care at a particular time.

We have initiated further and more prompt advanced care planning discussions with
residents (as appropriate) and their families and loved ones.

Further supervisions have taken place with care staff to cover care quality matters such as
respect and dignity, oral hygiene, choice, infection control, health and safety, safety checks,
COSHH, safeguarding, amongst other matters. Please see Appendix 2 for an example copy
of the supervisions undertaken with care staff.

Action was taken in relation iii and, following the incident with Mr Capstick, she was
immediately taken off front line nursing duties. ||was investigated in line with the
Company's employment procedures. A formal disciplinary meeting was held, and no
disciplinary action was taken against her, however a range of actions were required and
undertaken before could return to nursing duties. Basic life support training was
refreshed and updated. This has been consistently refreshed — please see Appendix 3.
HE 2: required to work on day shifts only and undermine or the Clinical Lead’s
supervision until her competency had been appropriately and satisfactorily assessed as
being suitable to provide nursing care safely to residents.

As the Coroner was aware, a referral was made to the NMC, and this was acknowledged.
Beyond that acknowledgement, it is not known to us the exact status of the NMC’s
investigation post-triage, however currently has a live PIN and is not subject to any
NMC conditions on her nursing registration. The NMC has confirmed to us that it will
contact us to confirm the outcome of the investigation. In the meantime, JE remains
under our supervision and, as above, has undertaken further training and will continue to do
so on the required basis.

Company number: 4009674

Westmorland Court, High Knott Road, Arnside, Via Carnforth, LAS OAW
Telephone: 01524 761291
Fax: 01524 762640
Email: Manager@westmorlandcourt.co.uk

The Coroner will no doubt be receiving an update from the NMC direct, as recipients of the
Regulation 28 report. We understand that Phas completed a reflective account of
the incident relating to Mr Capstick and that this has been submitted to the NMC.

Ongoing monitoring

We trust that the above information provides the Coroner with reassurance that action has
been taken over a period of time in relation to a range of care quality matters including staff
training, leadership and governance, staff competence, environmental and auditing matters.
We also remain engaged with the ICB and Westmorland and Furness Council, having made
the notable and vast improvements which led to the cessation of the quality improvement
process, together with regulation by our overarching regulators, including as the CQC and

the NMC for nursing staff.

Yours sincerely

Registered Manager (RGN)

Company number: 4009674