Paul Batchelor

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Telephone: 03000 616161 

www.cqc.org.uk 

By email to: 
(

, PA to HM Coroner for Surrey 

)  

Ms Susan Ridge, HM Assistant Coroner for Surrey  
HM Coroner’s Court 
Station Approach 
Woking  
Surrey GU22 7AP 

17 December 2024 

Care Quality Commission  
Our Reference: 

Dear Coroner Ridge,  

Prevention of future death report  (PFD) following  an inquest into the death of 
Paul Rodney Batchelor 

Thank you for granting an extension to enable the Care Quality Commission (CQC) 
to respond to your report issued in regard to Mr Batchelor’s death at the Red House 
Care Home in Ashtead, Surrey. We offer our sincere condolences to the family of Mr 
Batchelor on their loss.  

The report outlined two matters of concern; the first of which was addressed to the 
CQC and Medicines and Healthcare Products Regulatory Agency (MHRA) and the 
second to The Red House (Ashtead) Limited. We would like to take the opportunity 
to provide relevant background information before responding to your matters of 
concern.  

Background: the role of the CQC  

The CQC was established on 1 April 2009 by the Health and Social Care Act 2008 
(‘the Act’). The CQC is the independent regulator of healthcare, adult social care, 
hospital and community trusts and primary care services in England. The CQC also 
protects the interests of vulnerable people, including those whose rights are 
restricted under the Mental Health Act. 

Page 1 of 6 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Act introduced a single registration system which applied to both healthcare and 
adult social services. Once registered with the CQC, providers such as The Red 
House (Ashtead) Limited were required to comply with conditions placed on their 
registration, as well as the Health and Social Care Act 2008 (Regulated Activities) 
Regulations 2010 (‘Regulated Activities Regulations 2010’) and the Care Quality 
CQC (Registration) Regulations 2009 (‘the Regulations’).  

The Regulations set out the essential standards of quality and safety that service 
users had a right to expect. The Regulated Activities Regulations 2010 were 
replaced by the Health and Social Care Act 2008 (Regulated Activities) Regulations 
2014 which came into effect from 1 April 2015. The Act requires the CQC to publish 
guidance about compliance with the requirements of the Regulations. 

Background: deaths and serious incidents reported to the CQC  

The Act also requires providers to notify the CQC of certain events such as serious 
injury or the death of a service user. When this happens, we obtain information from 
the provider and other sources to help us determine if there is an on-going risk of 
harm to others and whether the information suggests there was a breach of the 
regulations. Important questions we must consider include whether there has been a 
failure on the part of a registered provider to provide safe care and treatment 
resulting in harm or a significant risk of exposure to avoidable harm.  

Harm caused through acts or omissions by an individual are referred to the 
appropriate authority, such as the police. Our statutory powers do not allow us to 
impose or implement corrective measures directly onto a provider. We do, however, 
expect the provider to respond quickly and comprehensively to any incident to 
manage risk and provide safe care. We also expect any changes made to be 
imbedded into their usual practice and sustained.      

CQC Enforcement Powers 

1. 

If we find that a registered provider or registered manager is in breach of 
provisions within the Regulations or the Act, we can take action to make 
sure that they improve. The action we take should be proportionate to the 
impact that the breach has on the people who use the service, how serious 
it is and whether we can allow the provider time to meet the Regulations. 
Unless we are seeking to close a service, we aim always to follow up any 
enforcement action with another inspection to ensure that improvement has 
been made. If we find continued breaches of regulations, we may escalate 
our enforcement response. However, we always consider each case on its 
own merit. 

2.  We take enforcement action where there is a serious breach resulting in 

risk for people and where we cannot leave the registered provider to decide 
on the timescale for meeting the Regulations. Enforcement action can be 
undertaken using either our civil or criminal powers. Our civil enforcement 
powers include: 

a)  Issuing a warning notice;  

Page 2 of 6 

 
 
 
 
 
 
 
 b)  Impose, vary, restrict or remove a condition from the 

provider’s registration; 

c)  Suspend registration; or 

d)  Cancel registration. 

Where people are at immediate risk of significant harm, and we cannot be assured 
that unless we act people will come to serious harm we can use our 'urgent' powers. 
This means that in some cases we are able to take immediate action to suspend or 
cancel registration or impose, vary, restrict or remove a condition from the provider’s 
registration. 

Background: the provider and brief chronology  

Red House Care Home in Ashtead, Surrey, is a home with nursing for up to 26 
people. The provider is registered for the following regulated activities: 

•  Accommodation for persons who require nursing or personal care 
•  Diagnostic and screening procedures 
•  Treatment of disease, disorder or injury 

The location was inspected in 2014, 2016 and 2019. At the last full inspection in 
2019 the location was rated as outstanding. We conducted a further inspection 
focussed on infection prevention and control (IPC) in 2022. Focussed inspections 
are unrated but in this instance we were assured that the provider was managing 
and mitigating IPC risks.  

We learned from the provider of this tragic incident on 28 June 2023. Mr Batchelor 
died on 27th June having been admitted to the home on 26 May 2023. Following our 
serious incident protocol we gathered information from the provider about the 
circumstances of the death, their immediate actions and what measures they took to 
prevent further occurrence. Our initial contact with the provider commenced on 29 
June 2023 and we were informed by them of the cause of death on 9 October 2023.  

First matter of concern   

“There may be a lack of awareness of the need to ensure adequate support for the 
mattress extension or bolster when using nursing care beds with an extension frame 
fitted. And that without adequate support there is a risk of death in that the mattress 
extension can fall through the bed frame creating a sufficient gap for a person to 
become wedged or stuck.  

The lack of awareness of the risk may be compounded because when the mattress 
extension is fitted into the gap between the standard mattress and the footboard it 
may appear as though the bolster is adequately supported. Further that over time 
and use mattress deck extensions or other supporting framework can become 
detached or lost from the bed. Since this incident the court heard evidence that the 
care home and its sister care home have checked all existing extended profile beds 
and taken steps to ensure that they are fitted with the correct support.  

Page 3 of 6 

 
 
 
 
 
 
 
 
 
 However, the coroner is concerned that users of nursing care beds with extensions 
may need to be made aware of the circumstances of this death to prevent other 
deaths in similar circumstances”.  

Last year CQC contributed to a MHRA national patient safety alert (NPSA) on beds 
and bedrails and their guidance on safe use of bedrails. CQC promoted both 
publications through our provider bulletins in September 2023. These bulletins are 
sent to health and social care organisations registered with the CQC and are 
addressed for action by the registered manager or a senior manager identified to the 
commission beforehand (called the ‘nominated individual’). The CQC already 
signposted providers to the MHRA bedrails guidance on our website page 
‘Regulations for service providers and managers: related guidance’  

The MHRA guidance does not specifically address the risks of the device used in Mr 
Batchelor’s case. However, the NPSA, in conjunction with the MHRA guidance on 
medical devices and their medical device checklist are intended to support providers 
to understand risk areas more broadly concerning beds and associated equipment, 
the importance of correct use (in line with any manufacturer’s instructions), 
appropriate maintenance and training in their use.  

As a result of this tragic event, CQC regulatory leadership and policy teams arranged 
for the specific NPSA to be highlighted as an example on our page: National Patient 
Safety Alerts in adult social care.  

We have highlighted the MHRA NPSA on beds and bedrails; their guidance on 
bedrails, their medical device guidance and their medical device checklist in our 
November 2024 provider bulletin. The medical device checklist lists profiling or 
adjustable beds and we have made this link clearer for providers. 

We have also included the MHRA medical device guidance and accompanying 
medical device checklist on our website page ‘Regulations for service providers and 
managers: related guidance’, which is shown in the link above.  

In addition, our policy and regulatory leadership teams will be including references to 
the NPSA and relevant MHRA guidance into our new assessment framework, 
although we are currently developing our approach to this. 

The NPSA itself was directed to care homes (among other organisations) and 
included requirements for adequate training on these devices, as well as 
requirements for regular servicing and maintenance.  

Based on subsequent discussion with the MHRA, CQC learned that the instructions 
for use for the bed included clear diagrams on how to extend the bed correctly and 
the instructions for use also specified the requirements for regular servicing, carried 
out by an appropriately trained person.  

This should have picked up the issue of the missing deck and the circumstances of 
how this happened in this case and what remedial actions have been undertaken 
since have been addressed with the provider by the CQC.  

Page 4 of 6 

 
 
 
 
 
 
 
 
 
 
 
 Second matter of concern   

“The coroner notes that the care home has taken steps to ensure that any resident in 
distress and calling for help at night is heard. However, though the coroner has been 
shown minutes of briefings to care home staff conducted after Mr Batchelor’s death 
emphasising the need to conduct checks of residents by going into a resident’s 
room, she remains concerned that such briefings have not been formalised into care 
home policy and procedures. Nor do the minutes of those briefings explain what staff 
should do if they are frightened or concerned about entering a room on their own. 
There is the risk that rather than disturb a resident care home staff through, for 
example, fear or lack of time do not check a resident who may be in distress.”   

Since receipt of your report, we contacted The Red House (Ashtead) Limited to 
obtain evidence to help us determine the results of any additional action they intend 
to take in response to the prevention of future death report.  

We received 56 submissions from the provider, including records relating to additional 
staff training in respect of managing challenging  behaviour; modified policy, training 
and competency records as well as other interventions such as the implementation of 
‘QR codes’ placed in residents’ bedrooms so that staff, when completing night checks, 
need to enter the bedroom to scan the code on a handheld electronic device to record 
the check on the care monitoring system. The home management team explained they 
were investigating options for acoustic monitoring to be installed. We were informed 
that, as stated at the hearing, the staff member involved in the incident was no longer 
working at the care home.  

Having  reviewed  the  material  the  provider  submitted,  our  view  is  that  the  changes 
made by the provider have now been established.  

From a regulatory standpoint, there is always the risk that remedial plans put in place 
after  an  event  of  this  nature  might  not  stay  embedded  into  normal  practice  or 
sustained. Therefore we will continue to monitor and assess the care home utilising 
information obtained from our insight data as well as other stakeholders such as the 
local  authority.  We  do  not  exclude  other  assessment  methodologies  such  as 
unannounced inspection visits, but for obvious reasons we would not wish to disclose 
details or intentions publicly.  

In conclusion, we will continue to work with our MHRA colleagues in relation to any 
other notifications of incidents occurring in the care sector involving harm to service 
users through entrapments in beds and associated devices. We will take robust action 
as necessary. 

Should you have any further questions, please do not hesitate to contact me.     

Page 5 of 6 

 
 
 
 
 
 
 
  
 
 
 
 Yours sincerely, 

Deputy Director  
South Network Team 3 

Page 6 of 6

Medicines & Healthcare products Regulatory Agency 
10 South Colonnade 
Canary Wharf 
London 
E14 4PU 

Ms Susan Ridge 
H.M. Assistant Coroner for Surrey  
By Email: 

Reference: 

25 October 2024 

Dear Ms Ridge, 

Investigation into an Invacare Portugal Lda, Medley Ergo bed with an extension 
and its relation to the circumstances surrounding the death of Paul Rodney 
Batchelor (DOD 28/06/2023). 

Thank you for your email of 16 September 2024 attaching the Regulation 28 letter 
following the inquest into the sad death of Mr Paul Rodney Batchelor. I would like to offer 
my sincere condolences to the family of Mr Batchelor on their loss.  

In your letter, you requested that action should be taken to prevent similar events of this 
kind occurring in the future. I would like to take the opportunity to provide relevant 
background before responding to your matters of concern. 

Introduction and regulation of medical devices in the UK 

The Medicines and Healthcare products Regulatory Agency (MHRA) is an executive 
agency of the Department of Health and Social Care and is responsible for the regulation 
of medical devices, blood components for transfusion and medicinal products in the UK.  

The MHRA takes all reasonable steps to protect the public’s health and safeguard the 
interests of patients, public and users. We ensure manufacturers of medical devices 
comply with the UK Medical Devices Regulations 2002 (as amended) to demonstrate that 
they meet appropriate standards of safety, quality, and performance for the expected 
lifetime of the device. Where possible, we work with a range of stakeholders, including 
patients and the public, to work towards the promotion of safer medical devices and their 
safe use.   

Manufacturers must demonstrate compliance with the Regulations before a medical 
device can be UKCA or CE marked and placed on the UK market. Although not 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 mandatory, device manufacturers can use designated standards to demonstrate that they 
are compliant with relevant requirements of the Regulations.    

One major area of the MHRA’s responsibilities is to collect, analyse, monitor, and act on 
information relating to safety concerns from a range of data sources including reports of 
adverse incidents. An adverse incident is an event involving a medical device, which 
produces, or has the potential to produce, unwanted effects involving the safety of 
patients, users, and other persons. These effects may arise from shortcomings in the 
device, its operating instructions, user practice or conditions of use. Adverse incidents 
may also occur due to patient factors, as not all interventions are suitable for all patients 
and their condition may change over time, requiring a different approach.  

Patient safety is our highest priority and we encourage everyone to report safety 
concerns to MHRA through our Yellow Card scheme. However, it is mandatory for 
manufacturers of medical devices to report certain incidents to MHRA.  

In general, where an adverse incident occurs the manufacturer of a medical device is 
responsible for carrying out any investigation required and informing MHRA of their 
findings. We regularly review our database of incidents to detect safety signals and 
consider whether additional action is required. Where necessary we will issue safety 
messages to health and care organisations, patients, and the public. These types of 
actions help to reduce the risk of similar incidents happening again. 

Synopsis of incident 

The MHRA was initially informed of Mr Batchelor’s death involving a Medley Ergo bed by 
Invacare Portugal Lda on 14 February 2024. Invacare first became aware of the incident 
on 5 February 2024 and reported within the regulatory timeframes. 

From the details within your report, Mr Batchelor was using a Medley Ergo bed with an 
extension frame manufactured by Invacare Portugal Lda. On 27 June 2023, Mr Batchelor 
was found trapped in the gap between the standard mattress and the footboard, after the 
extension section of the mattress fell through the gap. His death was formally recorded 
by paramedics on 28 June 2023. It was found that there was no deck in place to support 
the mattress extension. 

Matters of concern 

You expressed to the MHRA as a matter of concern that there may be a lack of 
awareness of the need to ensure adequate support for the mattress extension or bolster 
when using nursing care beds with an extension frame fitted. 

Prevalence of the problem 
A search of the MHRA’s database over the last 5 years (20 September 2019 to 20 
September 2024) yielded no similar incidents involving a patient becoming trapped 
between the mattress and footboard when a bed was extended, apart from this incident 
reported to the MHRA on 14 February 2024. This search was conducted for any bed, and 
not just the Medley Ergo. 

 
 
 
 
 
 
 
 
 
 
 
 Invacare Portugal Lda has searched their database of complaints and not found any 
similar complaints for the Medley Ergo bed. 

The wider issue of entrapment with medical beds is well known. A search of the MHRA’s 
database over the last 5 years (20 September 2019 to 20 September 2024) yielded 32 
reports of entrapment involving beds and associated devices such as mattresses, bed 
rails and bed grab handles. This includes reports of entrapment of caregivers as well as 
with bed occupants. 

MHRA response  

The MHRA reviewed the manufacturer’s User Manual. The User Manual provides 
general warnings regarding the risk of entrapment. The User Manual also includes 
instructions on how to install the mattress support extension, which includes the step 
“Attach mattress deck extender to the mattress deck”. These instructions are also 
accompanied by diagrams. There are also instructions on the need for regular servicing 
and maintenance, and that these activities should only be conducted by “personnel who 
have received the necessary instructions or training”. 

The MHRA carried out a review of deaths and serious injuries involving beds and bed 
rails in October 2022. In January 2023, the MHRA hosted a round table to discuss 
updating the Guidance on safe use and management of bed rails and how to raise 
awareness of the risks of death and serious injury with beds, bed rails, and other 
associated devices. As a result of these discussions, a National Patient Safety Alert on 
the risk of death from entrapment or falls with medical beds, trolleys, bed rails, bed grab 
handles and lateral turning devices was published in August 2023, two months after the 
sad death of Mr Batchelor.  

The Alert requires that relevant staff receive device training suitable to their 
roles, organisations have an up-to-date medical device management system in 
place, and that regular servicing and maintenance of these medical devices is 
implemented in line with the manufacturer's instructions. It also requires regular risk 
assessments for patients using bed rails or handles, including entrapment risks. 

This Alert was directed towards care home staff, among others, and was sent to relevant 
organisations via the MHRA’s Central Alerting System on 30 August 2023 and was also 
highlighted in the CQC’s Adult Social Care Bulletin on 28 September 2023. The MHRA 
attended meetings with Medical Device Safety Officer (MDSO) network on 
implementation of the Alert and provided input into the MDSO network’s FAQs for this 
Alert. The is available both on the MDSO network (restricted access) and also on the 
National Association of Medical Device Educators and Trainers (NAMDET) webpage 
(public access). The MHRA has also provided advice on the Alert wherever requested, 
including from various NHS organisations, local councils, care homes and manufacturers. 

The MHRA also published in 2014 ‘Devices in Practice’ which is intended to provide a 
practical guide for health and social care professionals on using medical devices. 

 
 
 
 
 
 
 
 
 
 Ongoing Work 

The MHRA has discussed with the NAMDET the possibility of producing training 
materials for users of beds and bed rails, and the risks relating to entrapment, and this is 
currently being drafted, with a view to be available in the coming months. 

Conclusions 

We suggest that the above list of actions detailed in the National Patient Safety Alert, 
published two months after Mr Batchelor’s death, are relevant to this case. Neither the 
MHRA nor the manufacturer have received any similar reports with the Medley Ergo bed, 
and the MHRA does not have any similar reports for other beds either, relating to the bed 
extension. The MHRA has published a National Patient Safety Alert with general 
requirements to prevent entrapment with beds and associated devices and based on the 
lack of similar reports relating to bed extensions, we believe these requirements are 
sufficient, and we therefore do not intend to take further action. 

The MHRA will continue to monitor reports of entrapments in beds and associated 
devices very carefully, and if any adverse signals are detected in the future, we will take 
further action. 

Should you have any further questions, please do not hesitate to contact my office: 

. 

Yours sincerely, 

Chief Executive 
Medicines and Healthcare products Regulatory Agency 
E:

Ms Susan Ridge HM Assistant Coroner for Surrey 
Woking Coroners Court 
Station Approach 
Woking 
GU22 7AP 

29 October 2024 

Dear Madam 

The Inquest Touching the Death of Paul Rodney Batchelor  
Regulation 28 Report – Action to Prevent Future Deaths – The Red House Care 
Home dated 13 September 2024 (the “Report”) 

We refer to the above and write to provide our response to the Regulation 28 Report 
to Prevent Future Deaths, received on 16 October 2024. 

The  covering  email  from  the  Coroner’s  Officer  confirms  that  the  due  date  for  our 
response is 56 days from the Report, so 8 November 2024. 

This response is made under paragraph 7(2) of Schedule 5 of the Coroners and Justice 
Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 
We  understand  the  response  must  contain  detail  of  action  taken  or  proposed  to  be 
taken, setting out a timetable for action.  Otherwise, we must explain why no action is 
proposed. 

We have addressed the Second Concern in the Report as below: - 

The  coroner  notes  that  the  care  home  has  taken  steps  to  ensure  that  any 
resident in distress and calling for help at night is heard.  However, though the 
coroner  has  been  shown  minutes  of  briefings  to  care  home  staff  conducted 
after  Mr  Batchelor’s  death  emphasising  the  need  to  conduct  checks  of 
residents  by  going  into  a  resident’s  room,  she  remains  concerned  that  such 
briefings have not been formalised into care home policy and procedures.  Nor 
do  the  minutes  of  those  briefings  explain  what  staff  should  do  if  they  are 
frightened or concerned about entering a room on their own.  There is the risk 
that rather than disturb a resident care home staff through, for example, fear or 
lack of time do not check a resident who may be in distress.  

We provide a list of actions taken and the relevant dates for each as follows: - 

Action Taken 

Review of staffing levels 

of 

Date 
Action 
26/06/2023 

Urgent Flash Reflective Debrief meeting  29/06/2023 
29/06/2023 
Staff meeting – flash 

Date  Evidence  Sent 
to Coroner 
ATTACHED 
29/10/2024 
26/01/2024 
30/08/2024 

The Redhouse (Ashtead) Limited 
43 Skinners Lane, Ashtead, Surrey, KT21 2NN 
Telephone: 01372 274552 | Email: redhouse@redhouseashtead.co.uk | Web: www.redhouseashtead.co.uk 
Company Registration No. 03187173 

 Individual supervision with DS (Carer) 

29/06/2023 

Lessons learnt session with DS (Carer) 
Lessons learnt session with SM (RGN) 
Lessons learnt session with DP (Carer) 
Night allocation – reviewed 
--monthly  Bed  Condition  Reports 
instigated 
Challenging Behaviour Support training 

29/06/2023 
29/06/2023 
29/06/2023 
05/07/2023 
Dec 2023 

30/04/2024 

Staff meeting – Flash 
General staff meeting 
General staff meeting 

03/07/2024 
09/08/2024 
14/08/2024 

Group supervision / lessons learnt 

17/09/2024 

Individual staff supervision – all staff 

18/09/2024 

Permanent staff Induction amended 

19/09/2024 

Agency staff Induction amended 

19/09/2024 

Bed Inspection report 

Night staff Meeting 

Staff  Deployment  and  Retention  policy 
updated  
Post Incident Training delivered by Legal 
Professionals  
Reviewing 
the  options 
monitoring to be installed at the home 

for  acoustic 

19/09/2024 

20/09/2024 

23/09/2024 

11/10/2024 

ATTACHED 
29/10/2024 
26/01/2024 
26/01/2024 
26/01/2024 
In oral evidence 
In oral evidence 

ATTACHED 
29/10/2024 
30/08/2024 
30/08/2024 
ATTACHED  
29/10/2024 
ATTACHED  
29/10/2024 
ATTACHED  
29/10/2024 
ATTACHED  
29/10/2024 
ATTACHED  
29/10/2024 
ATTACHED  
29/10/2024 
ATTACHED  
29/10/2024 
ATTACHED  
29/10/2024 
29/10/2024 

Ongoing 

In oral evidence 

Group supervisions, staff meeting minutes are made available to all staff and form part 
of the procedures of the home.  

Challenging behaviour training was conducted by Elgee Training on 30 April 2024 and 
incorporated the following.  The narrative from the trainer is as below: -  

The learning outcomes were: 

• Understand what behaviour that challenges is and what person-centred values are,

how to recognise triggers & report them

• Understand the needs of the people we support so their care is needs led
• How to keep you safe if a resident is violent or aggressive
•

Produce a positive behavioural support plan

My brief and, therefore, my narrative for the training was: 
Identify  challenging  behaviour  theory  and  meaning,  De-escalation  techniques,  principles  of 
positive behavioural support, ABC process (to identify triggers to this behaviour), 

The Redhouse (Ashtead) Limited 
43 Skinners Lane, Ashtead, Surrey, KT21 2NN 
Telephone: 01372 274552 | Email: redhouse@redhouseashtead.co.uk | Web: www.redhouseashtead.co.uk 
Company Registration No. 03187173 

 Actions  to  avoid  being  restrained  or  attacked,  post-incident  actions,  record  keeping,  de-
briefing, 
Why do people challenge – often because of unmet needs (so what are they?). 
These unmet needs would have become a group exercise and would have included, not enough 
sleep, being disturbed, hungry, cold, thirsty, lonely, uncomfortable, too hot, too much noise, 
you not understanding me, in pain, need the toilet etc.  

Know when to walk away (this is in the handouts too), and either hand the situation on to a 
colleague or get some help at that stage. 
Make sure incidents are recorded and the information passed on to the shift leader.  
Make  sure  that  you  have  not  placed  yourself  in  a  vulnerable  position  when  entering  a 
residents’ room or go in with a colleague. 
Don’t ignore these challenges. Record and report them otherwise they can become normalised 
(and then they don’t get seen) 

During my discussions, I would have mentioned that if we can determine what triggers the 
behaviour that challenges, and then avoid the triggers by changing our behaviour, then the 
incidents won't happen. 

To record this, we use the ABC method. 

The Mental Capacity Act determines that if residents have capacity, then they have the right 
to say no, and to live their life the way they want it, if that is possible within the confines of a 
care home. 
Any  changes  would  trigger  a  review  of  that  resident’s  care  plan  –  your  care  plans  and 
appropriate risk assessments are reviewed 4 weekly or sooner.  

Post incident action 
The  Red  House  has  taken  several  steps  immediately  following  the  incident.  
The  Manager  met  with  care  staff  the  following  day  and  conducted  reflective 
practice/lessons learnt with the staff present during the incident. 
The Manager then met with all staff, who were made aware of the risks of not 
responding to a call for assistance from a resident and the tragic consequences 
that  can  occur.    All  staff  received  individual  supervision  sessions  and  group 
supervision where this incident was discussed, and measures put in place to 
prevent a recurrence. 
Staff  were  instructed  that  if  they  felt  unsure  for  any  reason  responding  to  a 
resident  call  for assistance,  then they  are to  inform  a  colleague  and  enter  in 
pairs,  or  the  duty  nurse.    The  individual  supervision  with  DS  (carer)  clearly 
outlines what action to be taken if she felt unsure about entering a resident’s 
room.  

The Redhouse (Ashtead) Limited 
43 Skinners Lane, Ashtead, Surrey, KT21 2NN 
Telephone: 01372 274552 | Email: redhouse@redhouseashtead.co.uk | Web: www.redhouseashtead.co.uk 
Company Registration No. 03187173 

 
  
  
 
 
 
 The staffing levels in the home were reviewed on 26 June 2023 and a change 
to the allocation of night staff was made to ensure all floors had care support 
throughout the night. 
Since the inquest concluded, we have communicated to all staff the coroner’s 
concerns  and  whilst  we  believe  this  was  an  isolated  and  unforeseeable 
occurrence, the home has continued to reinforce the learnings to the present 
time, being 16 months following the incident.  
A  policy  was  in  place  at  the  time  of  the  incident  (the  Room  Call  Policy  and 
Procedure)  for  care  staff  to  respond  to  call  bells  and  has  been  extended  to 
include if a resident was verbally calling out for assistance.  The policy is that 
there is to be no exceptions ever to physically checking on a resident.  We will 
keep our policies under review to ensure that any positive changes to them will 
be made for the benefit, health, and safety of the residents. 
QR codes are now being placed in the residents’ bedrooms so that staff, when 
completing night checks, must enter the bedroom and scan the code using the 
handheld PCS device to record the check on the care system.  
The home had further post incident training on 11 October 2024 delivered by 
legal professionals versed in care matters.  
The home is also investigating options for acoustic monitoring to be installed.   
All  staff  training  is  maintained  above  98%  compliance  and  staff  have 
competency assessments to ensure their knowledge and skills are current and 
up to date. 
As stated at the hearing, the carer involved is no longer working at The Red 
House and I would like to assure you their actions in no way reflect the high 
standard of care that staff at The Red House deliver. 
The staff team have been shocked and saddened by the events that led to the 
death of our resident PB and have embraced the changes that have been made 
to mitigate the risk of this happening again in the future. 
Mindful  of  the  changes  that  we  have  implemented  above,  and  which  will  be 
continuously  monitored  and  reviewed  going  forward,  we  believe  that  all  our 
residents  are  appropriately  monitored,  they  are  not  left  unattended  and  the 
environment that they live in is safe. 
We hope we have addressed and allayed the concerns of the Coroner in our 
response above. 
Yours sincerely 

Registered Manager

The Redhouse (Ashtead) Limited 
43 Skinners Lane, Ashtead, Surrey, KT21 2NN 
Telephone: 01372 274552 | Email: redhouse@redhouseashtead.co.uk | Web: www.redhouseashtead.co.uk 
Company Registration No. 03187173