Ian Simpson

2nd floor 
2 Redman Place 
London 
E20 1JQ 
United Kingdom 

1 September 2025  

Mrs Heidi Connor  
Senior Coroner for Berkshire  
Berkshire Coroner’s Office  
Reading Museum and Town Hall  
Blagrave Street  
Reading  
RG1 1QH   

Dear Mrs Connor, 

We are writing following further consideration of the issues raised by the very sad death of Ms 
Ellen Mercer. Our thoughts continue to be with her family. 

We have reflected on the circumstances surrounding Ellen’s death and the concerns raised in 
your report, specifically that policies do not require assessment of VTE risk in people presenting 
at the emergency department. 

As we noted in our earlier response, we have published a guideline on venous 
thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or 
pulmonary embolism [NG89]. The guideline makes recommendations for VTE risk assessment 
for people admitted to hospital and we recommend assessing all medical patients to identify the 
risk of VTE and bleeding as soon as possible after admission to hospital or by the time of the 
first consultant review (recommendation 1.1.2). 

Since our previous response, NICE’s guideline surveillance team have thoroughly considered 
the issues raised in your report against our published recommendations and reviewed the issue 
you raise with topic experts. As a result of this, we will amend our recommendations in the 
guideline NG89 to say that people should be assessed to identify the risk of VTE and bleeding 
after a decision to admit to hospital, or after 12 hours in ED, or by the time of the first consultant 
review, whichever is sooner. 

Additionally, we will amend our recommendations on pharmacological VTE prophylaxis to state 
that this should be started as soon as possible and within 14 hours of the decision to admit the 
person (rather than within 14 hours of admission as at present) where VTE prophylaxis is 
indicated. We hope that these amendments will address the issue of VTE prophylaxis for people 
who have a prolonged wait in the emergency department.  

Thank you for bringing Ellen’s case to our attention and we hope that this further update is 
helpful.   

nice.org.uk | nice@nice.org.uk 

 
 
 
 
 
 
   
  
  
 Yours sincerely, 

Chief Medical Officer, Deputy CEO and Interim Director of the Centre for Guidelines, NICE 

, CBE MD FRCS FRCEM 

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FAO: HM Assistant Coroner Mr Potter  
HM Coroner’s Court for Inner North London 

By Email Only  

7th July 2025 

Dear Sir, 

Inquest touching the death of Mr. Ian George Stanton Simpson 
Magnolia Court (the ‘Home’) 

I write further to the Inquest of Mr. Simpson and the Prevention of Future Death 
Report issued on 12th May 2025 and sent to Barchester Healthcare on 13th May 
2025.  

Barchester Healthcare has carefully considered the issues identified at the 
hearing and as detailed in the Findings and Conclusion ruling received on 30th 
April 2025. It was deemed necessary to investigate the circumstances 
surrounding Mr Simpson’s deterioration on 16th December 2025 and steps 
taken in response by the staff on duty further.  

We set out the steps taken following the Inquest and the findings of our 
investigation below. We confirm we have updated the Care Quality Commission 
(‘CQC’) and will share a copy of this letter with them.  

Findings   

We have now spoken with all relevant staff working on the shift on 16th 
December 2024.  

We confirm Barchester has found: 

•  it is highly likely the deterioration occurred after 09:45am on 16th December 
2024. 
•  the entry made in Mr Simpson’s records at 09:46 in relation to repositioning is 
likely to have been made in error and most likely relates to another resident as 
this care intervention did not take place with Mr Simpson. 
•  it is not clear where the time of 09:30am as the time of the incident originates. 
Whilst this is recorded in the Accident and Incident Form, no member of staff 
suggested that there were any concerns at this time in respect of Mr Simpson’s 
health and wellbeing.  

 
     
 
 
 
 
 
 
 
 
 
 
 
 • Despite the evidence given, no other member of the Nursing team considered 
that 49 minutes is an appropriate length of time to escalate concerns to 999 if a 
resident is found unresponsive and staff did not recall there being any significant 
delay in doing so in Mr Simpson’s case.  

Steps taken after the Inquest  

Following the Inquest, we considered it necessary to ensure staff were clear as to 
the organisation’s expectations in relation to deteriorating residents. We 
acknowledged there was a need to improve staff understanding and use of 
EnabLE, the electronic record keeping. It was also apparent greater care was 
needed in the completion of Accident and Incident Forms which of course 
represent valuable sources of key information, if accurate. We have taken 
appropriate action in relation to staff members where departure from the 
organisation’s policy was identified on investigation.  

New General Manager  

We have appointed an experienced General Manager for the Home who has been 
leading on supporting the necessary improvements and staff development. 

Introduction of EnabLE  

EnabLE was introduced in December 2024. Our objectives were to standardise 
recording, increase visibility of day-to-day care interactions at management 
level, improve our ability to audit and conduct trend analysis of incidents and 
staff performance. We are confident the introduction of this digital care support 
planning system will allow the organisation to continually improve the standard 
of record keeping and delivery of prompt and effective care. Now our care staff, 
as distinct from nursing staff, have handheld devices and are expected to record 
narratives at the point of care which represents a completely new way of 
working for them having previously completed minimal resident records on 
paper. 

Implementation of EnabLE represented a significant project for the organisation. 
Training and coaching were provided by an implementation team to our staff 
before, during and after introduction 
of the system. We are aware that there was a period in which staff were 
familiarising themselves with the use of the handheld devices and completion of 
prompts scheduled against resident care plans to ensure care interventions are 
in a timely manner, use of free text and drop-down options.  

 
 
 
 
 
 
 
 
 
 Following the Inquest, we have provided refresher training at the Home in 
relation to the functionality of the system, the organisation’s expectations and 
policy in relation to record keeping and the importance of accurate and 
contemporaneous recording.  

We have the ability to review the documentation completed by staff at the Home 
remotely; the Regional Director and Regional Clinical Development Nurse 
continue to consider the quality of entries as part of the ongoing assurance audit 
programme. We are currently working on setting up a trial of an integrated 
digital accident and incident recording system, this will be linked to the digital 
care planning system to allow for the capture of key information relating to the 
incident in real time which will support our investigation of incidents in future.  

Barchester Healthcare Policy in relation to Deteriorating Residents 

We confirm the following steps have been taken at the Home to ensure that staff 
are clear as to our expectations in relation to residents who appear to be unwell: 

•I presented learning from this matter to all our home managers during our 
‘Leading the way’ internal communication webinar on 19th May 2025. This 
session covered responsibility to escalate any concerns in relation to residents’ 
health and welfare and utilise the guidance provided in our Deteriorating 
Resident’s Policy and that 999 must be immediately called for an unresponsive 
resident where this represents a new presentation. 

•Themed supervisions have been completed with the support of Divisional 
Clinical Lead Nurse, the Clinical Development Nurse and both the Regional 
Director and General Manager of the Home. These themed supervisions cover 
two main areas: 

•RESTORE2 – which includes ‘clinical judgement’ (RESTORE2 is a physical 
deterioration and escalation tool for care/nursing homes based on nationally 
recognized methodologies including early recognition (Soft Signs), the national 
early warning score (NEWS2).  

•Managing Resident Deterioration. 

The themed supervision programme was completed by the end of June and 
ongoing learning and development is planned for the Home. 

 
 
 
 
 
 
 
 
               
 
 •Staff in the Home have also been provided with Barchester ‘Clinical Shots’ 
guidance, to inform their assessment of residents and the steps to be taken in 
response. 

As above, the Regional Director is monitoring the care provided at the Home to 
ensure the learning has been embedded. The Regional Director will continue to 
review resident incidents during their monthly visits to the Home.  

We have taken the opportunity following our investigation to review the 
Appropriate Admission Policy to ensure that careful consideration is given to 
residents with more complex needs. At the Quality First Conference in 
September, which will be attended by all General Managers, I will be delivering a 
workshop on appropriate admissions which will encompass learning from a 
number of cases including this one.  

We take all concerns raised extremely seriously and wish to reiterate that the 
health, safety and wellbeing of our residents is of paramount concern. We hope 
this explanation offers reassurance that the risks of recurrence of issues 
identified on investigation have been mitigated in so far as possible.  

We offer our condolences to Mr Simpson’s family and friends for their loss. 

Yours faithfully 

│ Director of Nursing │ Barchester Healthcare 
 │

 │www.barchester.com