Sally Mills

AS Chiltern Homecare Ltd
T/A Caremark (Three Rivers & Chiltern)
5 Greenway Parade
Chesham
Buckinghamshire
HP5 2DA

5th December 2024

Dear Madam Coroner,

Inquest touching the death of Sally Mills
I write in response to the Prevention of Future Death (‘PFD’) report made at the conclusion of the Inquest

touching the death of Mrs Sally Mills which was received by way of email on 16th October 2024.

I was present at the Inquest on 11th October 2024 and listened to your concerns regarding the evidence

given by Caremark’s witnesses during the hearing. Caremark is committed to continuous improvement, and

we have taken the concerns raised seriously. The health, safety and wellbeing of the people we support is of

paramount importance. For completeness, I am responsible for the implementation of the steps being taken

in response to the PFD and for monitoring their effectiveness moving forwards.

Steps immediately after the Inquest

On 14th October 2024 I met with 

, Care Manager, to discuss the outcome of the Inquest and

the steps required to address the concern’s raised. I confirmed it was imperative for us to take steps in order

to ensure the organisation was operating in a safe manner. We also discussed the Carer involved in the

incident, and the need, to not only ensure her well-being given her experience of the hearing, but to also

make sure she had the required level of knowledge and understanding to carry out the responsibilities of her

role.

Concern 1 - Basic Life Support Training

The evidence revealed there is still a lack of understanding of providing basic life support to those

becoming unresponsive.

Following the Inquest, we had concerns regarding the effectiveness of the first aid training being delivered to

our care team. We have carefully considered how best to assess the current level of understanding of the

care team and to supplement their learning and experience to date.

Prior to the incident our basic life support training was delivered by Total Training Solutions via their on-line

platform. This on-line training included a knowledge check at the end. In August 2023, 

 joined

our team who is ‘Train the Trainer’ qualified and was tasked to deliver in person refresher training for our

staff which ran for around one hour on an annual basis. This was extended to a 3 and a half hour session

from 31st October 2024 and also covered manual handling techniques.

At present, all members of our care team are in date with their mandatory training which includes refresher

training sessions in basic life support. 

 is responsible for ensuring that all care team members

complete the required training within the relevant time frame, and this is managed via People Planner. There

 have been no other issues identified in relation to first aid since Mrs Mill’s sad death. I set out the changes

we have made to date below.

In person Basic Life Support training from January 2025

We have now engaged the support of an external provider, The Training Centre (London) Ltd to deliver in

person Basic Life Support training to our staff. The first session will take place on 21st January 2025. The

session will train up to 12 members of staff and as such 4 sessions in total will be arranged at the beginning

of 2025. The session will comprise demonstrations, practice of practical skills and a competency assessment

at the end. All staff will be required to pass the competency assessment. This session will cover attending to

a person who is unresponsive (and breathing, unresponsive and not breathing) and where choking is

suspected.

Our intention is to seek feedback from the provider as to the frequency of refresher training and format to be

adopted moving forwards. At this stage, we confirm that our basic life support training will be delivered in

person from now on both in terms of the induction programme and the refresher sessions.

Given the importance of the issue, we have decided to add first aid as an agenda item to all of our full team

meetings or regular supervision sessions. We will discuss any issues encountered and talk about the best

practices which should be follow. As well as giving care assistants an opportunity to raise any concerns or

seek any further clarifications.

Ongoing support for Carer
On 7th November 2024 
were no concerns in relation to her continuing to work with our clients. On 19th November 2024 the Carer has

 held an annual review session with the Carer to ensure that there

undertaken a further basic life support refresher training session. We considered this would help build

confidence after the incident and the subsequent inquest experience.

The Carer has also received a targeted supervision session to discuss the learning and allow for further

reflection. We continue to provide pastoral support to her as needed. The feedback in the supervision form

confirms, ‘[the Carer] answered all of my questions [regarding the training] correctly and I could tell there is a

lot more knowledge and confidence in how to deal with an emergency’.

Concern 2 - Escalation of issues encountered by Care Assistants
Evidence demonstrated efforts have been made in this regard, such as a new checklist and new
policy dated September 2023; the evidence revealed a lack of knowledge of the policy and the
embedding of it.
The care team are the organisation’s eyes and ears on the ground and as such we are reliant on them to

communicate their concerns to the office in a timely manner. It became apparent that further work should be

undertaken to embed section 2.27 (Raising Concerns) of the Medication Procedures September 2023 (the

‘Policy’) and ensure staff are familiar with and understand its requirements.

We have decided that the Policy will also be discussed with staff at the full team meetings held in December.

Our agenda for the next team meeting on 10th December 2024 includes medical emergencies, who to

contact, first aid training scenarios and a read through and discussion of the Policy and our First Aid Policy.

Staff will also be reminded of the location of the Policy on their app, should they wish to review this in real

time. Training scenarios cover trips and falls, severe bleeding, choking and breathing difficulties.

 The requirement to contact the office when in doubt will also be emphasised as part of our induction

programme for new joiners. The scenarios listed in the Policy are not exhaustive, we recognise the need to

encourage and empower our care team to exercise professional curiosity and that will also be explored in our

full team meetings. We would be happy to share the minutes of the meetings if that would be helpful.

Additional Task added to Care Plan
The additional task added to the care plan for each individual who our carers are assisting with their

medication (Level 2 administrations) remains in place.

Caremark’s expectations
We have decided to extend our induction programme to include an in person walk through of our policies

and procedures, please see the programme attached. The walk through will facilitate discussion, allow time

for questions and enable the team members delivering the session to assess the extent to which new joiners

understand Caremark’s expectations. The sessions will also provide an opportunity to identify new joiners

who may require additional support before they can commence caring for our clients. New joiners will not be

placed on rotas until the team is satisfied, they understand the requirements of our policies.

Finally, our induction session Care Mark Assistant Practical Mandatory Training regarding ‘Golden Rules’ in

relation to medication recording has also been amended to refer to the Policy to ensure there is consistent

and clear messaging throughout our suite of guidance in relation to recording and identification of

‘medication incidents’.

I hope that is a helpful summary.

Yours sincerely,

Managing Director