Sylvia Savage

Mr J E Thompson 
Assistant Coroner for County Durham and Darlington 
H.M. Coroner’s Office 
P.O. Box 274 
Stanley 
Co. Durham 
DH8 1HG 

11 February 2025 

Dear Mr Thompson 

Regulation 28: Reply to the report to Prevent Future Deaths (‘PFD‘) in relation to Mrs Sylvia Savage  

Thank you for your comments at the conclusion of the inquest into the very sad death of the late Mrs Sylvia 
Savage. This letter sets out a response to the comments and the PFD report directed to the Four Seasons 
Health Care Group (‘the Group’). 

May I firstly express my condolences to Mrs Savage’s family for their loss. Please be assured that the safety 
of those in our care is the Group’s absolute priority. 

During the inquest that took place between 9 and 12 December 2024, you heard evidence from the Home’s 
 about initiatives and measures undertaken at 
Manager 
Redwell Hills Care Home (‘Redwell’ or the ‘Home’) following the death of Mrs Savage. The Group has supplied 
information on the following issues: 

 and Regional Manager 

1.  

2.  

Training of staff at the Home in relation to record-keeping and archiving 

The Home’s falls policy and processes   

We now write to give you assurance that further steps have been taken and actions implemented to address 
the matters raised at the Inquest. These have been incorporated into the ongoing provision of care services 
at the Home and have been shared more widely across our business as part of our approach to learning and 
continuous quality improvement.  

As an organisation, the Group strives to learn from all incidents affecting our residents or team members. 
The Group has considered aspects of care service delivery and practice in the Home openly and honestly, 
and where any lessons learned can be cascaded throughout the wider organisation to improve our overall 
care quality.  The regional team and the senior/executive management team will continue to review your 
findings  and  disseminate  and  implement  any  consequent  recommendations  accordingly  throughout  the 
organisation.  

Our  organisation  includes  a  dedicated  Quality  Team,  with  responsibility  for  process  improvement,  this 
includes direct support for each home. Regional Managers are regularly present in our care homes and are 
responsible for facilitation, monitoring and progress checking of change and improvement activity, alongside 
other members of the regional team. 

I have detailed the concerns raised in your PFD report below followed by confirmation of the steps that the 
Home and Group have taken and will continue to take regarding these concerns. 

Norcliffe House, Station Road, Wilmslow, Cheshire SK9 1BU  T: 

Four Seasons Health Care and brighterkind are part of the Four Seasons Health Care Group. 
Four Seasons Health Care Holdings Limited, Registered Office: Norcliffe House, Station Road, Wilmslow, SK9 1BU. Registered in England. Company number: 03806216 

 
 
 
 
 
 
 
 
 
 
 
 
 Matters of concern 

“1. There was I heard no clear definition of when to report falls externally & internally – this to me is perhaps 
the reason why the fall Mrs Savage suffered on 1/2/23 was not recorded internally, all be it CQC were notified 
on this occasion. The fall on 18/3/23 was not reported to CQC and whilst I understand staff at the care home 
did not know the outcome of Mrs Savage’s treatment in hospital – she left the home by ambulance and did 
not return.  This seems an occurrence worthy of reporting – it strikes me some clearer reporting structure is 
necessary – timely and accurate reporting both internally and to regulators allows for those concerned to 
assess  the  care  home  and  decide  on  whether  there  are  risks/issues  that  need  addressing  and  protect 
residents.  I would suggest over reporting is preferable to under reporting.”  

As set out in the witness statement of 
 dated 2 December 2024, the Group strives to learn from 
all incidents affecting our residents or team members. The Group has considered aspects of care service 
delivery  and  practice  at  the  Home  and  across  the  Group  openly  and  honestly  alongside  your  expressed 
concerns.   

The Group includes a dedicated Quality Team, with responsibility for process improvement, including direct 
support for each home. Regional Managers are regularly present in our care homes and are responsible for 
facilitation,  monitoring  and  progress  checking  of  change  and  improvement  activity,  alongside  other 
members of the regional team. 

The Clinical Risk Management Policy (also exhibited to 
’s statement) was adopted by the Group in 
2021,  with  a  body  of  supporting  material  for  guidance  on  falls  risk  and  post-falls  management.  Falls 
Awareness training was introduced as part of an induction program to new home starters across the Group 
from April 2020 and then as mandatory training for all care and clinical team members from April 2021.  

A Falls Process Flowchart has formed part of the new system in place after April 2021. Since April 2021, all 
care and clinical team members must complete falls awareness training, delivered by a learning management 
system complemented by on-site face to face training.  

The Group operates a digital incident management platform (RADAR)  which allows team members of all 
grades to report incidents affecting residents, team members and any visitors to the care home. The system 
also offers prompts to ensure appropriate categorisation of the incident and to support necessary further 
actions including referral to external agencies and management by regional support teams.  

All  Home  Managers,  Deputy  Managers  and  members  of  the  Group’s  regional  team  receive  mandatory 
training on the use of RADAR and how to complete a report and any subsequent investigation.  

When reporting a fall, a series of mandatory questions require answers to the following prompts – time and 
place, personal factors, environmental factors and any potential injury. The system asks for a description of 
the incident and what action was taken at the time. The team also have the option of uploading statements 
and  pictures  to  aid  an  investigation.  All  incidents  reported  to  RADAR  are  subject  to  investigation.  The 
investigation is to be completed within 14 days, although this can be completed sooner if the detail is known 
to close the investigation or extended if a third party become involved such as the police, safeguarding and 
CQC. Notifications to local safeguarding teams are completed in line with local safeguarding requirements. 
CQC notifications are completed in line with CQC statutory notification requirements.  

When any incident is reported to RADAR the Home Manager receives a notification via email. Incidents of a 
high level of seriousness are also alerted to regional and senior team members across the Group.  

Each home in the Group is required to complete an incident analysis each month which is produced via the 
RADAR  system,  this  is  then  validated  during  the  Regional  Manager  Provider  Validation  Review  which  is 

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 carried  out  each  month.  This  seeks  to  support  consistency  of  application  of  Group  policy  and  affords  an 
opportunity for the regional team to address any issues quickly to inform ongoing practice. 

A  replacement  learning  management  system,  “Your  Hippo”,  a  Skills  for  Care  Endorsed  Provider,  was 
deployed at the end of 2023. Any new team members joining the business must complete all mandatory 
training  within  the  first  two  weeks  of  commencing  employment.  Your  Hippo  uses  a  blended  learning 
approach which consists of induction, training and shadow shifts to ensure that all colleagues are supported 
and integrated in the most effective way. During monthly audit visits undertaken by Regional Managers or 
Regional Support Managers, a selection of training records is reviewed to ensure compliance. 

The Group works with external healthcare partners to manage falls risk, including GPs, district nurses and 
community falls prevention services: the exact resources vary between localities. The new overarching Falls 
Policy (exhibited to 
’s statement) was adopted by the Group in May 2024, with specific focus on 
the management of referrals.  The Falls Policy was designed to pull together existing documentation and 
processes regarding falls protocols, flow charts, person centred care planning expectations, risk assessments 
and risk management procedures. The Falls Policy also includes our expectations regarding what action we 
expect of our teams of all levels, when a resident experiences a fall.  

Whilst we aim to empower residents to sustain and maintain their mobility for as long as possible, the Falls 
Policy advises our teams to refer falls to external support teams, where needed. When falls are logged to 
RADAR,  prompts  ask  the  team  member  completing  the  notification  to  consider  a  referral  to  the  local 
community falls team and review equipment usage. 

Falls monitoring is part of the key care indicators analysis produced by the Group’s Incident Analytics Lead 
and shared with operational team members for review and identification of trends, or emerging risks, to 
agree action, if any, is required. Further to this, the Group’s Quality Team provides additional support to 
homes where a high prevalence of falls is identified, which may include visits to the home to discuss actions 
with the Home Manager. Redwell Hills does not provide nursing care, and the care team works closely with 
external healthcare partners to support the nursing care needs of residents.  

Each  Home  Manager  completes  monthly  trend  analysis  using  RADAR,  which  allows  them  to  identify  any 
patterns in terms of people, places, times of day etc where falls are more prevalent.  This in turn allows the 
Home Manager the opportunity to review risk reduction measures already in place and identify additional 
appropriate action such as a referral to external healthcare partners. RADAR also supports oversight by the 
Regional Manager and other members of Regional Management to ensure that correct practice is embedded 
and followed, including referrals and reports to relevant external partners and notifications to appropriate 
regulators.  Regional  Management  visits  take  place  on  a  regular  basis  to  ensure  the  completion  of  all 
documentation  and  appropriate  escalation  of  any  care  needs  and  this  includes  a  review  of  selected  (at 
random) care files. 

Team members must document any concerns about our residents on RADAR straight away and the Home 
Manager  and  Senior  Care  Assistants  carry  out  spot  checks  and  sitting  in  on  handovers  to  support  this.  
Refreshed  training  around  RADAR  reporting  of  falls  has  been  introduced  within  the  Group  in  the  last  12 
months, in conjunction with the roll-out of the Falls Policy, and the senior team at Redwell Hills has received 
this via the learning management system. 

Residents who are showing any signs of deterioration have physical observations put in place and recorded 
for monitoring and these will be discussed with the Home Manager or Senior Care Assistant so that referrals 
may be made to health professionals quickly.  Team members are to escalate any concerns as soon as they 
are noticed. Deteriorating residents are discussed in the daily flash meetings and any actions identified are 
then followed up by the Home Manager or deputy. 

Team members at the Home have been reminded that handovers from one shift to the next must contain 
details of the resident’s needs, which will include equipment to be used, settings and frequency of aids and 

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 appliances, risks in respect of mobility and falls, skin integrity, hygiene, continence, choking, nutrition and 
support required for each care need and risk identified.  Handovers will also identify any incidents such as 
falls during the shift, including those which may signal a need for a review of risk assessments or a referral 
to healthcare professionals. The handover which takes place is verbal using a written document as a record 
of the information shared. 

“2. The evidence is clear that the provided sensor mat was not an efficient way of monitoring Mrs Savage 
when she attempted to mobilise.  It was well known in the home that Mrs Savage defeated it’s purpose by 
moving or unplugging it.  There seems to have been a lack of thought as to an alternative measure.  The wall 
mounted sensor, for example was seen by the expert as a reasonable measure – the home manager said he 
could consider them and the regional manager indicated they were used in the company, but not at the care 
home where Mrs Savage was residing.  It seems to me the home should have an armoury of measures to pick 
from to tailor the needs of the individual resident not just limited to one particular measure.  The risk of death 
is obvious to others if persons at high risk of falls are not known to be moving by those charged with looking 
after them”. 

Mrs Savage had been admitted to the Home initially as a temporary placement on 14 December 2022. For 
new admissions, upon receipt of a referral or enquiry, details about the person to be admitted to our homes 
will  be  taken  and  a  pre-admission  assessment  will  be  completed.  The  information  obtained  at  the  pre-
admission stage will seek to include everything that the home requires to ensure that the needs of the person 
can be met safely, and to ensure that there is continuity of care, treatment and support for the person, and 
this information is used to commence formulation of care plans and risk assessments, including mobility 
needs and falls risk. All risk assessments are to be completed within 12 hours of admission and care plans 
finalised within 72 hours, these documents are reviewed monthly as a minimum, or as a change in resident 
need is identified.  

Following  any  hospital  stay,  when  a  resident  is  due  to  be  discharged  back  to  the  care  home,  the  Home 
Manager or senior representative will complete an assessment to establish any change in need, including 
mobility  and  falls  risk,  to  be  certain  that  they  can  still  meet  those  needs.  On  re-admission  to  the  home, 
individual  risk  assessments  and  care  plans  are  to  be  reviewed  and  updated,  where  required,  within  a 
recommended timescale of 12 hours. A series of How to Guides gives additional support to team members 
in specific clinical and support areas, including a How to Guide on the assessment of falls risk. 

We strive to mitigate falls risks whilst recognising that sensory equipment cannot of itself prevent a fall but 
provides staff a signal of a resident moving or mobilising and a window to attend the area where movement 
has been detected to assist the resident. Certain incidents may be categorised as a “near miss” as staff have 
prevented a possible fall from happening and will inform ongoing practice just as a fall in terms of lessons 
that may be learned. 

Residents’ wishes are respected as part of the care planning and risk assessment process with a view to 
ensuring that clear evidence of risk has been explained and understood. Whilst respecting that Mrs Savage’s 
rights to freedom of movement and independence with mobilising were empowered by the team at Redwell 
Hills, we acknowledge that further assessment of reticence to utilise the sensor equipment in place, and 
consultation with Mrs Savage’s family members, may have further supported the falls management process.  

The Group has access to a range of sensor equipment to support the needs of residents, including infrared 
motion detectors. Sensor mats are often favoured as they alert teams to a resident attempting to mobilise 
and  can  be  moved  with  the  resident  if  they  choose  to  sit  in  lounge  areas,  for  example.  Infrared  motion 
detectors can be troublesome for residents who can walk short distances independently as they will ring 
constantly when the resident is moving around their bedroom and the noise and consequential agitation 
that may be experienced may lead to further risk of harm or injury. It cannot be said with any certainty that 
Mrs Savage would have responded better to a different sensor measure, but it is acknowledged that the care 
provided  to  Mrs  Savage  following  her  falls  on  1  February  and  18  March  2023  was  reactive  rather  than 

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 proactive and that although there were multiple discussions regarding her care, further interventions such 
as consideration of a wall mounted sensor were not deployed. 

Following the concerns noted at the inquest, regional teams have reminded all Home Managers as to the 
scope  of  equipment  available  to  them  through  the  Group  procurement  department,  to  support  falls 
reduction.  This  equipment  is  available  to  any  resident,  in  accordance  with  their  assessed  needs  and  risk 
assessment.  Regional teams will incorporate this into their regular audit of home practices.  

On  reflection  a  focussed  meeting  with  Mrs  Savage’s  family  should  have  taken  place  and  discussion  held 
around  her  dislike  of  the  sensor  mat.  A  best  interest  decision  could  have  been  made  and  an  informed 
decision taken on whether it was more detrimental to have the sensor mat in place. In addition, the Home 
could have discussed and considered infrared motion monitoring equipment as an alternative.  

 recognises the responsibility to take forward the lessons learned, share these with the team 
and ensure they are implemented and sustained moving forward. An important lesson was  communication 
with residents’ families as to the different areas of care needs. Positive dialogue is to be constantly promoted 
in respect of any areas of concerns of high need, as well as being transparent and person centred at all times. 

The  Home  now  operates  more  positive  lines  of  communication  with  families,  including  them  in  the  care 
decisions and providing as much information possible to support informed decisions, as evidenced in some 
of  the  positive  feedback  the Home  has  received  though  Customer  Satisfaction  Surveys and  other  ad-hoc 
review processes. 

“3. Mrs Savage’s fall in February 2023 was it appears reported to her GP by her daughter and that led to a 
nurse attending the home to examine her.  Staff at the home do not appear to have done so themselves.  It 
is of concern that after a fall the staff within the home should have a mechanism to ensure medical advice is 
obtained  in  a  timely  fashion  and  that  it  is  documented  clearly  and  not  be  reliant  on  family  members 
summoning help for residents themselves when they have become aware of an incident.”  

As  detailed  below,  a  number  of  courses  have  been  undertaken  by  the  care  team  at  the  Home  covering 
refresher training on obtaining professional medical advice promptly in appropriate circumstances. 

The Home has adapted practice around falls team referrals sent through the Community Matron, focussing 
on a wider scope of equipment used to mitigate the risk of falls.  

All Home Managers now take part in a Falls Forum attended by Regional Managers and Group management 
on a monthly basis. Discussion focusses on falls in the Group’s homes and what we are doing to mitigate risk 
and achieve the best, safe support for our residents. This allows best practice to be reinforced and any new 
initiatives to be cascaded quickly. 

All visiting professionals including General Practitioners will now be prompted and requested to complete 
the Visitors Book on arrival to the Home and to await a member of the team to announce their arrival so 
that they can be accompanied on all visits by a senior member of the care or clinical team, to ensure that 
any  advice  or  recommendations  can  be  communicated  as  needed.  Senior  Care  Assistant  staff  or  a  Unit 
Manager  on  duty  will  go  with  the  healthcare  practitioner  when  they  attend  and  review  and  treat  our 
residents. The Senior Carer will then document information in the Healthcare Professionals Visit form. The 
information  recorded  will  confirm  the  time  and  date  of  the  visit  and  the  name  of  the  practitioner.  The 
practitioner  will  be  asked  to verbally  agree  that  the  information  and  details  are  correct  or  advise  of  any 
changes as necessary or appropriate and the date of the next visit will also be recorded.  

All significant visits and communications/conversations with visiting health professionals should be recorded 
in the visiting professionals’ section of the resident care plan in any event, with a carer making an accurate 
record of the visit and any recommendations or actions and shared in the handovers of any resident who 
has received a professionals visit that day. 

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 The Home Manager or Deputy Manager will review the Healthcare Professional Visits records during monthly 
audits and will escalate any concerns immediately. 

A Themed Supervision for Senior Carers is now in place which sets out the procedure above. A reminder 
about the process to all care home staff is contained in the daily Flash meeting template/agenda. 

 “4. The absence of records has hindered my investigation into Mrs Savage’s death.  The expert in her evidence 
made it clear – good recording keeping allows staff to monitor changes in her condition, allows new staff or 
those returning from time off to reacquaint themselves with residents’ condition and allows clinicians to make 
diagnosis – without access to good records I can see a clear risk to the care of residents.  It is also surprising 
to me the complete reliance on paper records which have in Mrs Savage’s case have been lost.  I would have 
expected to see electronic recording of information and electronic storage of it.  I note the roll out of this in 
the company has been paused whilst the company is awaiting sale, and my concern is whether the electronic 
recording and storage will be implemented – to me immediate access to records of a resident or absence of 
them creates concern”  

We acknowledge the shortcomings in record-keeping at Redwell Hills as addressed in the Home Manager’s 
statement of 1 December 2023. Record-keeping training and guidance has been heavily promoted within 
the Home since the issues were identified in connection with Mrs Savage’s death. All existing clinical and 
care team members have been required to refresh mandatory courses on record-keeping training. Care plan 
and documentation training was booked for team members at the Home as a face-to-face course following 
the incident and has taken place regularly with multiple sessions covering the full care team, the last taking 
place on 8 August 2024. The courses have covered contemporaneous noting of daily events, professional 
visits and emerging risks, entries in the Group’s incident management system, RADAR, and proper archiving. 

A new “How to Guide” for archiving was published and distributed throughout the Group in October 2024, 
providing clear standards and expectations around the care, storage and safe keeping of records.  A training 
module on the Group’s learning management system is also being developed and roll out is expected shortly.  
This will be additional guidance for the Home’s teams in relation to GDPR and the safekeeping and storage 
of records.  

As stated in the Home Manager’s statement, the How to Guide for archiving has been shared with the team 
in group supervisions and confirmed in team meetings. Expectations for storing and archiving paperwork 
have been confirmed with the team and they are aware as to the importance of accurate record keeping. 
Additionally: 

• 
• 

• 

• 

• 

Storage is a mandatory agenda item at meetings that are held every six to eight weeks. 
The Home Manager has discussed the lessons learned around this matter in handovers and flash 
meetings.  
The Senior Care team and Home Manager are completing daily checks of room documentation and  
the information recorded on that to ensure quality and accurate content. 
On each unit the Home has a filing cabinet for staff to store records at the shift end, then at the end 
of the month the Senior Care Assistants check files and documents are archived appropriately to 
ensure a complete history of resident care needs and care delivery. The process has been explained 
and  demonstrated  to  each  member  of  staff  and  recorded  in  supervisions,  including  on  the 
completion of all daily notes and charts and the required detail to be captured. 
The  Home  Manager  and  Regional  Management  will  continue  to  drive  the  importance  of  this 
documentation  to  permanent  and  support  staff  with  knowledge  and  accountability  for  record 
keeping. 

Regular monitoring and support are given by the Unit Manager, Home Manager, Deputy Home Manager and 
Regional  Support  teams  to  ensure  all  care  staff  understand  the  importance  of  effective  record-keeping. 
Senior Care Assistants in the Home check charts for all residents throughout the day and sign the charts in 
red pen and report any defaults, omissions or errors or matter of concern to the Home Manager or Deputy 

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 Manager on the same day. Daily notes and room charts are also checked by the Home Manager and Deputy 
on daily walk rounds and at the Flash meeting, where any concerns or information required are discussed 
and staff reminded to report any concerns to the Home Manager or Deputy in their absence. 

Staff at the Home have been reminded that handovers from one shift to the next must contain details of 
residents’ needs, which will include equipment to be used, settings and frequency of aids and appliances, 
risks in respect of skin integrity, hygiene, continence, choking, mobility and falls and nutrition and support 
required for each care need and risk identified. Supplementary documentation in use for each resident and 
the requirement for it to be competed on shift are also highlighted. 

Falls and record-keeping awareness remain constant agenda items discussed within the daily flash meetings 
which  are  attended  by  all  senior  team  members  and  department  heads  on  duty.  A  daily  walk  round  is 
completed by the Home Manager and the senior care team and all issues identified are discussed at the next 
flash meeting or sooner with relevant members of the team as necessary to ensure resident safety. A sample 
of care plans are checked each month to ensure compliance with the Group’s processes   

The process for daily record-keeping and storage of records has been explained to each member of the team 
and recorded in supervision notes, countersigned to confirm understanding. Throughout 2024 the Group 
rolled-out  electronic  medicines  administration  records  (‘eMAR’)  as  part  of  continued  investment  in  our 
homes, notwithstanding a sales process launched in June 2024. The system removes a lot of the paper in the 
medication process and with live reporting supports improved visibility at home and regional level.   This 
investment in eMAR followed a wholescale Wi-Fi upgrade programme and serves to modernise and digitise 
a  key  area  of  how  we  work.  The  Group  is  piloting  electronic  care  records  at  several  homes  as  part  of 
continued efforts to digitise intensive manual processes.  In the meantime, the importance of proper record-
keeping and archiving is a regular agenda item at flash meetings.  

Supervisions  have  been  completed  with  all  care  team  members  at  the  Home,  regarding  the  standard 
required  in  respect  of  completion  of  care  plans,  risk  assessments  and  supplementary  documents  and 
particularly room-based charts which document (for example) positional changes and food and fluid intake 
and daily notes updated at each observation. The supervision records also note the importance of recording 
communications  with  visiting  professionals.    As  part  of  the  supervision  exercise,  the  importance  of 
completion of all daily notes and charts, to ensure the level of detail is accurate, including details of falls, 
skin integrity, incontinence, diet, social engagement and mobility was discussed. The areas listed above are 
revisited regularly at flash meetings. 

“5. The evidence I have heard is after Mrs Savage’s fall on 1/2/23 and when it became clear the sensor mat 
was not working as intended – this should have prompted staff to return to the care plans and re-evaluate 
them – it did not.  Indeed, one care home witness stated as Mrs Savage had not had 3 falls in 3 months no 
change to her plan was needed.  Given the second fall Mrs Savage had some weeks later gave her injuries 
that led to her death this approach appears flawed.  Whilst I acknowledge work is ongoing in this area it 
appears that prompt re-evaluation of the care plans after events such as a fall are necessary to prevent injury 
and death – I would ask for some reassurance that significant events are captured by staff and in turn their 
significance is carefully considered and if necessary changes made to care.”  

All care plans and risk assessments are reviewed monthly as a minimum. Each section of the care plan is to  
be  reviewed  more  frequently  should  a  change  in  need  be  identified  or  a  risk  highlighted,  for  example 
following a fall or other incident. As regards  mobility care plans these should be evaluated following any fall 
or near miss or if any other change in need is apparent, for example a resident diagnosed with an infection 
which may impact balance.  

We keep under review and if needed update the policies referenced above for all staff providing residential 
care at the Home and the Group more widely. 

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 Thank you for raising your concerns. I hope that the content of this letter provides sufficient assurance that 
the Four Seasons Health Care Group takes the concerns raised seriously, has acted following the death of 
Mrs Savage and has accepted the points raised and continues to work to improve the services we provide. 
Should you have any questions or concerns or comments, please do not hesitate to contact me directly. 

Yours sincerely 

Director of Governance and Quality 
Four Seasons Health Care Group 

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