John Riley

Response to the Coroner's Regulation 28 Report to Prevent Future Deaths 

1. THIS RESPONSE IS MADE ON BEHALF OF 

The Manor House Care Home  

2. REGULATION 28 REPORT 

This response follows a report by Jacqueline Lake, Senior Coroner for Norfolk. 

3.

INVESTIGATION AND INQUEST

On 22 February 2024, the Senior Coroner commenced an investigation into the 
death of John Riley, aged 73, who died on 8 February 2024 at The Manor House 
Care Home.  

The  investigation  concluded  at  the  end  of  an  Inquest  on  15  November  2024, 
conducted  by  the  Senior  Coroner.  The  Senior  Coroner  gave  a  conclusion  of 
Accident.  

The medical cause of death was: 

1a) Neck fracture 
1b) Fall 

4. CIRCUMSTANCES OF DEATH 

Mr Riley suffered life changing injuries in a road traffic collision in 1976 and was 
dependent  on  others  for  his  care.  Mr  Riley  entered  The  Manor  House  Care 
Home in 2017 and was provided with personal care. His mobility was severely 
limited. Risk Assessments found that Mr Riley was deemed at low risk of falling 
out of bed. His bed was to be placed at the lowest setting when unattended and 
he was subject to two hourly checks at night time. On 8 February 2024, Mr Riley 
was  checked  at 01.10  hours  and  03.00  hours. When  checked  at  about  05.25 
hours,  Mr  Riley  was  lying  on  the  floor  with  the  bed  frame  under  his  neck. 
Emergency services were called and Mr Riley was declared dead at the scene. 
The evidence does not reveal the means by which Mr Riley came out of bed and 
onto the floor. Mr Riley died from a fracture to his neck. 

5. CORONER’S CONCERNS

The  MATTERS  OF  CONCERN  are  as  follows  (as  stated  on  the  Coroner's 
Regulation 28 Report to Prevent Future Deaths): 

I. 

Evidence was heard that observations were sometimes not carried out 
every two hours as required. In January 2024 observations were late on 

 ten occasions and on one prior occasion to 8 February 2024 in February 
2024. 

II. 

Evidence was heard that some action has been taken by Manor House 
Residential Home to reduce late observations. Evidence was also heard 
that some observations are still being carried out outside of the two hour 
period. 

6. ACTION TAKEN 

The management at The Manor House Care Home has taken this matter very 
seriously. An internal investigation and Root Cause Analysis were undertaken 
following  the  incident,  and  the  management  at  the  home  have  continued  to 
review  their  processes  throughout,  and  following,  the  Senior  Coroner's 
investigation into the death.  

The Manor House Care Home is a residential care home for 48 residents. Care 
is provided twenty four hours a day in shifts. Between 7pm and 7am, there is a 
senior carer supported by three night carers on duty. The care team undertakes 
welfare observations of every resident throughout the night shift.  

The  NICE  guidelines  do  not  provide  a  standard  for  the  frequency  of  welfare 
checks, but determine that every care home should ensure regular monitoring 
of residents' wellbeing based on the individual needs of its residents. The Manor 
House Care Home operates a system of two hourly welfare observations.  

The Manor House Care Home notes the concerns of the Senior Coroner. The 
Home  wants  to  reassure  all  reading  this  report  that  they  have  reviewed  their 
policy as to the frequency and timeliness of welfare observations, and that steps 
have been taken to address the concern that observations were sometimes not 
carried out every two hours as the Home requires of itself.   

In order to provide clarity, night staff previously undertook welfare observations 
in pairs. Care staff operated in pairs since should personal care also be required 
most, if not all, residents require two members of staff for the safe provision of 
their personal care. Each pair previously undertook the welfare observations for 
half of the residents within the home. Each pair of care staff moved from one 
resident to the next, administering personal care as required as they progressed 
round  the  home.  The  delays  identified  by  the  Senior  Coroner  occurred  when 
residents  required  extensive  personal  care  or  attention  during  the  welfare 
observation, which would then delayed the carers as they progressed to the next 
resident.  

Following  the  Inquest, The  Manor  House  Care Home  has  made the following 
changes: 

 1.  Following the handover to the night staff at 7pm, each pair of care staff 
goes  to  their  assigned  areas.  They  undertake  a  walk  around  together 
whereby they check each resident.  

2.  Between  7pm  and  9pm,  those  residents  not  already  in  their  room  are 

given the choice to be assisted to their rooms.  

3.  The  two  hourly  welfare  observations  commence  at  9pm  and  are 
undertaken thereafter at 11pm, 1am, 3am and 5am before the day staff 
commence their shift at 7am. 

4.  For  the  purpose  of  the  two  hourly  welfare  observations,  the  home  is 
divided  into  four  sections.  Each  staff  member  on  duty  is  assigned  a 
section for the duration of their shift. The home has a maximum capacity 
of  48  residents  and  so  each  staff  member  is  assigned  the  duty  of 
undertaking the welfare observations for a maximum of 12 residents. 

5.  Each staff member on duty is required to undertake a visual observation 
of  each  of  their  12  residents  at  least  every  two  hours.  The  individual 
members of care staff then re-join their partner upon completion of their 
respective observations to attend those residents requiring personal care 
in a priority order.  

6.  This approach ensures that welfare checks are undertaken at least every 
two hours without the prospect of the observations being delayed by the 
provision of personal care.  

7.  Welfare checks are recorded electronically via a handheld device onto 
the  resident's  social  care  record.  The  timeliness  of  the  welfare 
observations undertaken the previous night is reviewed for five different 
residents  daily  by  the  Home  Manager.  This  random,  daily  auditing 
process  ensures  that  the  timeliness  of  the  welfare  observations  is 
monitored daily, which further ensures compliance.  

In conclusion, The Manor House Care Home wants to reassure all reading this 
report that the above actions are confirmed as embedded into practice as of the 
date of this response. 

7. THIS RESPONSE HAS BEEN PREPARED BY

, Solicitor, DWF Law LLP on behalf of The Manor Care Home. 

8. DATE OF RESPONSE 

10 January 2025