Christiana Dawson

DARNALL GRANGE NURSING HOME  

                              84 Poole Road, Sheffield, S9 4JQ  

                                              Tel 

 Email: 

24th October 2024 

Tanyka Rawden 
Senior Coroner - South Yorkshire West 
Office of H.M Coroner 
The Medico-Legal Centre 
Watery Street 
Sheffield 
S3 7ES 

REF: Darnall Grange Care Home – The Late Christina Betty Dawson 

Dear Mrs Rawden, 

I write to provide a copy of the report produced by our company in response to your 
letter dated 16th October 2024. 

We have reviewed your findings and provide a response and actions. We have also 
provided this to CQC and our Local Authority. 

We believe this addresses all the points highlighted by yourself as well as trying to 
clarify inaccuracies by third parties. We have included documentation including the 
original MAR Charts received every month, agency nurse induction which has been 
updated  to  include  istumble  and  post  fall  protocol.  If  you  would  like  a  copy  of  the 
nurse/team leader attendance sheet this can be provided if required. There are only 
2 members of the senior staff team that have not had the revised training session as 
they were both off sick and will have the training prior to them commencing back at 
work. 

If you have any further questions about the response, please do not hesitate to contact 
me. 

Yours Sincerely 

Registered Manager 
Darnall Grange Care Home 

Registered Office: Hermes Care Ltd – Unit3, Old Brickworks Lane, Chesterfield, S41 7JD 
Registered No: 07429058 England & Wales 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Summary and Approach of our actions 

The  coroner  commented  that  the  care  plan  provided  did  not  pre  date  the  homes 
electronic system. This was available as we do store our paper documents for 6 years. 
For the analysis we have carried out we have used the time period that the coroner 
reviewed. 

Our  analysis  included  looking  at  the  following  key  areas  such  as  fall  prevention 
measures, equipment used, risk assessments completed and actions taken, review of 
the  fall in terms of timings, locations,  environment,  whether  it was witnessed,  the 
outcome  of  each  fall.  We  looked  at  medication  management  and  communication 
between  the  GP  practice  and  the  home  and  the  pharmacy.  We  reviewed  the 
orientation of agency staff and their knowledge of our procedures and how they were 
trained and what information we hold on each member of staff. 

ROOT CAUSE ANALYSIS 

FALL PREVENTION MEASURES 

1.  Why weren’t further measures taken to reduce the person’s risk of further 

falls? 

The falls that occurred from 30/03/2022 to the last fall 16/03/2024: 

We have reviewed the post falls information, the accident forms filled in at the time 
of the incident, the analysis carried out by the home manager and the revisited falls 
risk assessment. 

It can be seen that prior to the first fall on the 30/3/2022 that the equipment in place 
was the ultra low electric hospital bed, a pressure sensor alert mat,  a de cluttered 
bedroom as Christina mobilised with a zimmer frame which was always kept in close 
proximity. 

The corridors and lounges also are free of clutter and equipment wherever possible 
as we are aware of our client group being wondersome. 

The  issue  raised  by  the  coroner  was  that  the  post  falls  review  carried  out  by  the 
manager  did  not  clarify  if  any  further  steps  or  equipment  could  be  put  in  place. 
Looking  at  the  equipment  in place  and  the  review  that  was carried  out  we  feel  no 
enhancements could be utilised to prevent the risk of falls, but we acknowledge that 
the review should have clearly stated that fact. This is a review point and action going 
forward. 

The equipment that was in place and also the zimmer frame were reviewed by the 
OT and deemed to be appropriate at the time. 

Page 2 of 9 

 
 
 
 
 
 
 
 
 
 
  
 
 
 On reviewing the falls analysis, it can be seen that 7 out of 10 incidents did occur in 
Christina  bedroom  and  the  equipment  in  place  was  functioning  and  helped  to 
mitigate  the  risk  of  serious  injury.  The  only  real  method  of  prevention  of  the  falls 
would have been to have 1-1 carers present which was not available due to her being 
a residentially funded client.  

The second part of the review post falls looked at the action of the staff at the time 
which showed they did follow the Company falls protocol, seeking external medical 
intervention and carried out neuro observations as per the policy.  

On 10/01/2024, due to the volume of falls over the previous 12 months, the OT visited 
upon the request of management team, to carry out an assessment. The OT assessed 
both  Christina’s  mobility  using  her  walking  aid/zimmer  frame  as  well  as  the 
environment and the equipment put in place in her room. The outcome of the review 
was  to  carry  on  care  as  planned  with  no  recommendations  to  changes  in  the 
equipment of which if there was the home would have acted immediately. 

The GP has visited on numerous times, all the reviews had no highlighted changes 
in strategy. 

The final fall, which was the second fall of the day on 16/03/2024, was an unwitnessed 
fall in front of Christina’s bedroom, on the corridor, at 21:30hrs. She was walking at 
the time with her walking aid. At 21:24hrs, she was in the lounge with members of 
staff who tried to encourage her to  allow them to get her ready  for bed, which she 
refused  and  then  left  the  lounge  area  and  started  to  walk  down  the  main  corridor 
which was normal for Christina. She fell prior to getting into her room and the staff 
responded immediately and took the correct course of action by alerting the nurse. 
The  nurse  has  stated  that  Christina  was  trying  to  mobilise  herself  and  trying  to 
crawl.  The  Company’s  policy  which  we  have  enclosed  and  “I  STUMBLE”,  a  falls 
assessment tool clearly states that in all 999 cases residents should be kept calm, still 
and comfortable and also on the post falls decision making tool within our policy it 
clearly  states  under  major  injury  highlighted  in  RED  that  patients  should  not  be 
lifted but kept comfortable and maintain their position wherever possible. 

These supporting documents along with our own falls management procedures make 
it clear that the nurse did not follow our procedures. The nurse involved no longer 
works  for  the  agency  as  she  has  emigrated  to  Australia,  but  the  agency  has  been 
informed in writing and provided with a copy of our very clear procedures and the 
need for these to be passed onto all future nurses that may work at Darnall Grange. 
As  part  of  the  agency  induction  sheet  a  post  falls  decision  making  tool  and  “I 
STUMBLE”  a  falls  assessment  tool  are  given  to  and  signed  for  by  ALL  agency 
workers. 

The  management  of  Darnall  Grange  are  having  face  to  face  meetings  with  Team 
Leaders and Nurses highlighting the Company’s procedures and policies on falls to 

Page 3 of 9 

 
 
 
  
 
 
 
 
 mitigate the risk of causing further injury after sustaining a serious injury. 

Conclusion:- 

It was acknowledged by the Coroner that the falls risk assessment had been reviewed 
after  every  fall,  however  the  Coroner  made  a  comment  that  these  reviews  did  not 
result in any change being made. The post falls monitoring had been carried out by 
the  staff.  The  company’s  policy  and  procedures  on  seeking  guidance  from  external 
health  professionals  including  GP,  OT  and  ECP  had  all  being  followed.  The 
equipment provided and the environment as assessed by the OT were deemed correct, 
but  we  acknowledge  with  the  coroner  the  post  falls  analysis  and  risk  assessments 
should have been made more robust making it clearer if other equipment could have 
been provided and if not to state to that affect. 

The  second  point  of  action  in  relation  to  our  falls/procedures/policies,  the  agency 
nurse induction clearly has copies of our documentation prior to their  commencing 
their first shift. This is signed for by the agency member of staff and the inductee. 

Our own staff including both nurses/team leaders and senior carers are having face 
to face meetings and will conclude by the 30th of October 2024. They have been already 
made aware of the policy, but the meetings are to reinforce the policy and also to get 
a signed confirmation that they understand the strategy. 

NEEDS ASSESSMENT REVIEWS 

2.  Why was the person re-admitted to the home if you could not meet their needs?  

Darnall Grange is a dual registered residential and nursing home. There are trained 
staff present on both floors 24 hours a day. 

The issue raised by the Coroner regarding applying for nursing care and our ability 
of meeting Christina’s needs: Christina had her bedroom on the first floor and had 
her care led by a team leader. The management team felt that Christina would be 
best placed, due to her care needs not just for falls, downstairs in the nursing unit. 
This does not retract from the fact that a qualified nurse does work upstairs and has 
oversight of the residents, but the care is led by the team leader for residential service 
users. 

The manager requested a DST to be completed while Christina was in hospital, so 
she could return to the ground floor, so the home could provide nursing care. 

The  manager  carried  out  a  face-to-face  review  prior  to  the  re-admission.  This 
confirmed we could meet her needs in the residential unit but would be better suited 
on the ground floor.  

The manager upon the request of the family directly, did accept her back with the 

Page 4 of 9 

 
 
 
 
 
 
 
 
 
 
 
 
 residential status, as he had done face to face review with Christina in hospital and 
felt he could meet the care needs. 

The manager at the time when he was questioned by the Coroner, was emphasising 
Christina’s deterioration and her increased care needs, which he felt met the criteria 
for nursing. The assessment carried out by the hospital by 3 independent assessors 
did not agree hence Christina’s’ needs were still classified as residential when she left 
hospital. 

Sheffield,  like  many  other  local  authorities,  uses  the  trusted  assessor  model,  but 
despite  this,  the  manager  still  carried  out  a  face-to-face  review  prior  to  Christina 
coming back, as a best practice. This review is documented within her care plan. 

Following Christina’s return to Darnall Grange care home as with all residents, the 
care needs are reviewed on a monthly basis and only on January 2024 did these needs 
deteriorate to a level where a DST was requested again. 

In  summary,  yes,  the  home  manager  did  feel  at  the  time  she  was  in  hospital, 
Christina had nursing needs, but after the assessments by three health professionals, 
this was not supported by them and they felt she had residential needs. 

If Christina had been assessed as nursing and returned to the ground floor, would 
have this prevented the falls? The answer is no, as the same equipment, environment 
and staffing levels will be present. 

The staffing level at Darnall Grange are two qualified nurse 24 hours a day and a 
further  qualified  nurse  within  daytime.  There  are  11-day  carers  within  the  home 
during the day and 5 at night time.  

The Manager does understand his obligation to meet resident  needs, and it clearly 
can be evidenced that he has refused residents to be re-admitted when he has felt he 
couldn’t meet the needs. He did feel he could meet the needs for Christina’s but felt 
that some of those needs met the nursing criteria which is very common on the grey 
area with assessment. 

Conclusion:- 
The  conclusion  is  the  home  could  meet  Christina’s  needs  and  the  impact  of  being 
returned to the residential unit on the first floor had no impact on the likelihood of 
her falls continuing. 

MEDICATION MANAGEMENT & SYSTEMS 

3.  Why the person’s anti-coagulation medicine continued after it had been 

Page 5 of 9 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 stopped by the GP?  

On  03/01/2024,  the  GP  did  carry  out  out  a  falls  review  for  Christina  which  was 
requested by the Home because of the high level of falls. The GP that visited was a 
locum GP, he stated at the time that he did not have a laptop, and he would return 
to the practice and review the medical notes and make any medical changes he saw 
fit and would directly inform the home with these changes.  

At no point did the GP nor the Surgery or Pharmacy contact us with any medication 
changes.  
Therefore    we  were  not  able  to  make  any  changes,  and  the  medication  regime 
continued.  

The repeat medication was delivered by the Pharmacy at the end of January 2024 as 
per normal with all the medication present, no changes at all. 

On  the  attendance  of  paramedics  on  13/02/2024  following  a  fall,  the  paramedics 
informed us that the GP had discontinued the anti-coagulant medication- Edoxaban 
30mg on 03/01/2024. 

We,  ourselves  checked  SystemOne  and  could  verify  that  SystemOne  did  state  the 
change of medication. The issues raised are that there was no GP contact to the home 
and the MAR sheets remained unchanged for the months up until March 2024. This 
is  evidenced  by  a  copy  of  the  original  MARS  sent  to  us  on  January,  February  and 
March 2024(please see attached). 

The SystemOne  does  show  that medication has  been stopped,  but  we  have limited 
access  to  SystemOne  except  for  requesting  medication,  not  adding  or  omitting 
medication as this can only be done by the GP or hospital staff. 

The  medication  was  stopped  by  us  on  the  13/02/2024  following  the  fall,  when  the 
paramedics informed us. 

Up until 13/02/2024 we had no direction to stop the medication. The new MARS were 
issued with all medication on them even up to an including March 2024. 

This was all reported to the Safeguarding at the time with the evidence as why we 
did not cease the medication, and the matter was closed. 

On the 24/01/2024, there was a number of medications reviewed that resulted in a 
number  being  stopped  as  listed:  CalciD3,  Cetirizine  1mg/1ml,  Lansoprazole  30mg, 
Memantine  20mg,  Mirtazapine  45mg.  These  were  stopped  immediately  as  per  the 
GPs request. 

The letter provided by the GP practice to the Coroner, was identified by the Coroner 
as not being accurate, as it wrongly states that the Home was told by DR. Rehan on 

Page 6 of 9 

 
 
 
 
 
 
 
 
 
 
 
 
 the 03/01/2024 to stop the anti-coagulant, but in reality, this was not done. 

The second inaccuracy is that it states that on 24/02/2024 DR. Abdula re-confirmed 
that  the  anti-coagulant  medication  should  be  stopped.  This  is  inaccurate,  as  on 
24/01/2024,  Dr.  Abdula  only  gave  the  instruction  to  stop  the  medicines  mentioned 
above, which we carried out and it’s evidenced by SystemOne. 

Conclusion:- 
In  conclusion,  the  medication  was  not  stopped  on  the  prescribing  portal  on 
SystemOne,  and  the  GP  did  not  instruct  the  home  to  stop  the  medication,  as  it 
continued  to  be  prescribed  and  dispensed.  The  inaccuracy  by  the  Surgery  on  the 
information given to the coroner regarding Dr Abdullah visit on the 24/1/2024  was 
not factual as the review did not include the Edoxaban. 

Going forward, SystemOne is now utilised as the  ordering and  checking system so 
that  we  check  the  dispensed  medication  on  a  monthly  basis  as  we  receive  it  with 
SystemOne notes of discontinued medication. 

Historically, the Home had a large numbers of locums covering our home. This has 
been highlighted in many meetings with the CCG and GP practice, but we are now 
allocated our own GP, and we can see improvements. 

In relation to the permanent GP being in post, we also have direct access with the 
community OT who visits the Home weekly, and we are carrying out two residents 
reviews per week. 

AGENCY STAFF SKILLS AND KNOWLEDGE 

4.  What actions have we taken to ensure agency staff have the right skills and 

knowledge? 

The utilisation  of agency  staff  is kept  to  a  minimum  as we  now have  our  full-time 
nurses in post. 
In  relation  to  our  care  assistants,  there  has  been  staff  that  had  meetings  with 
management. We have enforced the policy that if a resident had a fall, they are not 
to be moved until they have had a clinical assessment. 

With  regards  of  our  own  nurses,  meetings  are  being  held  commencing  21/10/2024-
30/10/2024  to  reinforce  our  policy  and  procedures  on  falls  and  obtain  written 
confirmation they have had this training. 

The nurse involved in Christina’s incident, who wrongly allowed her to be moved to 
her bed, no longer works for the Agency as she emigrated to Australia, therefore we 
had no opportunity to give her feedback. 

We have had a meeting with our Agency provider, giving them our policy, procedures 

Page 7 of 9 

 
 
 
 
 
 
 
 
 
 
 
 
 and protocols. The Agency provides full training, and they are invited to our training 
sessions and meetings. The Agency provides a full staff profile with the training and 
induction completed. 

A  comprehensive  induction(see  attached)  and  orientation  is  provided  to  every  new 
agency nurse which includes a copy of “I STUMBLE” and post fall decision making 
tool(see attached). 

Page 8 of 9 

 
 
 
 
 
 SUMMARY OF ACTIONS TAKEN QQ01  

Action Area: 

Details of Action Required 

Use System One to check there are no 
changes  in  medication  and  that  the 
MAR 
provided  match 
SystemOne 

charts 

falls  should  clearly 

The  falls  risk  assessment  carried  out 
post 
identify 
equipment  in  place  pre  fall  and  any 
additional  equipment  that  could  be 
supplied to mitigate risk further. If the 
equipment pre fall cannot be improved 
this  must  be  clearly  identified  and 
highlighted in the review. 
Staff  Meeting  scheduled  for  Darnall 
Grange  Nurses 
from  21/10/2024-
30/10/2024  to  re-enforce  the  policy  of 
not moving a service user post fall until 
clinical assessments have been done. 
Inform the agency of the outcomes and 
make them aware of the breach of our 
company policy with regards to moving 
a service user after a fall. 
The  induction  checklist  for  agency 
workers  has  been  updated  to  include 
the  protocol  on  falls  and  we  have 
included  the  “I  STUMBLE”  protocol 
and post falls decision making tool. We 
also hold staff profiles for each agency 
member  staff  provided  where  we  are 
able to see their skills.  

Yours faithfully,  

Who 
responsible 
action 
MANAGER 

is 
for 

When 
completed by 

to 

be 

Update  on  Progress  &  Date 
Completed 

ONGOING 

This  has  been  done  and 
completed  and  access  to 
SystemOne  is  available  for 
Darnall  Grange  and  the 
system is being used to check 
the  delivered  medication  on 
the monthly dispensing. 

MANAGER 

21/10/2024-
30/10/2024 

MANAGER 

ONGOING 

MANAGER 

30/10/2024 

HERMES 
COMPLIANCE 
TEAM 

ONGOING 

forms  part  of  our 
induction 

and 

This 
training 
process. 

Completed and Manager Ali 
Akbar  informed  the  Agency 
Concerned. 

This  is  ongoing  as  all  new 
agency members of staff will 
be  supported  pre  shift.  All 
existing  agency  staff  are 
attending  our  staff  sessions 
by 30/10/2024 

Nadim Admani 

Director 
Darnall Grange Care Home 
S&S Healthcare Ltd part of Hermes Care Ltd 

Page 9 of 9