Keith Inseon

For the attention of  
Mr Cousins 
HM Coroner for Blackpool and Fylde 
PO Box 1066 
Corporation Street 
Blackpool 
FY1 1GB 

Email to:  

Dear Sir, 

22 July 2025 

Inquest touching the death of Mr Keith Ineson 
Regulation 28: Report to Prevent Future Deaths 

I  write  on  behalf  of  Barchester  Healthcare  (the  owners of  Glenroyd  Care  Home)  to 
respond to the matter of concern raised by the Learned Coroner in the Prevention of 
Future Death Report (PFD) issued on 27 May 2025.  The PFD was issued subsequent 
to the conclusion of the inquest into Mr Keith Ineson which concluded on 23 May 2025 
at Blackpool Coroner’s Court.   

Mr  Ineson  very  sadly  died  in  hospital  after  a  choking  incident.    He  was  in  hospital 
where he was recovering from surgery performed subsequent, to a fall at Glenroyd 
Care home.  

The concern raised by the Learned Coroner related to the recording of observations.  
The Coroner confirmed that there was no evidence that observations had  not taken 
place  but  that  recording  of  observations  was  inadequate.  In  particular  the  PFD 
provides: 

It was noted in the evidence, that the observation scores taken for Mr Ineson following 
his  fall  had  not  all  been  recorded  in  Mr  Ineson’s  care  notes.  This  left  a  gap  in  the 
evidence as to reviewing the need for escalation to medical services after the fall. and 

I could not identify changes to the record keeping system though, and as such found 
that the issue around the absence of recording observation scores following a fall gave 
rise to a risk of further death. This was because the record keeping was inaccurate, 
contained gaps in the information, and engaged my duty under paragraph 7, Schedule 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners 
(Investigations) Regulations 2013. 

At the inquest the Learned Coroner heard evidence that observations had been carried 
out after the fall and that staff had escalated concerns to the out of hours service and 
general  practitioner.    Nevertheless,  as  stated  above  the  system  of  recording  was 
unclear and at times absent.   

Whilst  the  Coroner  has  asked  for  an  explanation  regarding  the  recording  of 
observations  Barchester  Healthcare  wishes  to  set  out  its  holistic  actions  which  go 
wider than the concern in the PFD.  Barchester Healthcare, were already embarking 
on the investment into a new digital system for observations, which coincided with the 
inquest.  This will also be set out in detail below. 

Barchester Healthcare wishes to reassure the Coroner that it is committed to learning 
from mistakes and experience and to encourage sharing of incidents in an open and 
transparent  way  with  staff  in  a  “no  blame”  culture  as  appropriate.  Barchester 
Healthcare takes these issues very seriously and consistently strives for improvement.   

On that basis It was deemed necessary by the organisation to conduct an investigation 
into  how  the  events  were  recorded  by  staff  following  Mr  Ineson’s  fall  on  26  April 
2024.Barchester  Healthcare  has  carefully  considered  the  matter  giving  rise  to  the 
concern in the PFD regarding the staff’s recording of observations at Glenroyd Care 
Home. 

Following  the  Inquest,  Barchester  revisited  the  issue  of  recording  of  all  resident 
interactions  and  observations  to  ensure  this  is  undertaken  clearly,  consistently  and 
contemporaneously. We acknowledge that there was a need to improve the accuracy 
and  regularity  of  record  keeping.  We  have  taken  appropriate  action  in  relation  to 
training and technology to ensure that all interactions with patients are recorded. 

Training 
Additional  training  following  the  incident  has  taken  place  reinforce  the  need  for 
appropriate responsiveness to incidents, as well as the need or clear documentation 
at all times.  We have focused on documentation after events to ensure that staff are 
clear about following the established guidance for escalation after falls. Actions and 
lessons learned from this have led to specific training in targeted areas.   Barchester 
Healthcare considers that on this occasion staff did escalate matters appropriately as 
in the evidence given, but we have taken the opportunity to share this sad case with 
staff  to  embed  the  actions  that  must  be  taken  after  an  incident  and  the  way  that 
observations  should  be  carried  out  and  recorded      We  are  confident  that  by 
implementing our new digital system as well as further reinforcement training staff are 
clear about the necessity for accurate and detailed recording (including observations).  

In addition, the members of staff involved in the incident attended a Moving & Handling 
refresher training day with an Operational Trainer on 3rd June 2024. The moving and 

 
 
 
 
 
 
 
 
 handling refreshers are routinely completed yearly with every staff member and are 
part of the three-day refresher.  This includes what to do after a fall.  

This  training  is  also  supported  with  e-learning,  as  well  as  specific  practical  training 
completed  by  the  Operational  Trainers on  the  refresher  sessions  with  slide  sheets, 
equipment as well as a session within the refresher where staff have the chance to 
discuss  more  complex  cases  to  learn  the  best  way  to  support  someone  with  more 
complexities with moving and handling to mitigate against falls happening in the first 
place.  

Digital Care Planning System 

The Learned Coroner will recall that in addition to the actions undertaken which were 
,  the 
set  out  in  the  action  plan  submitted  prior  to  the  inquest, 
Registered  Manager  of  Glenroyd  Care  Home  explained  that  Barchester  has 
implemented  a  new  digital  care  planning  system  called  EnabLE  which  provides 
Barchester healthcare services with the ability to set up planned post fall interaction 
scheduled observations that can be recorded at the point of care to ensure accuracy 
and eliminate  the risk of absent recordings. The system is relatively new, and we have 
completed some additional training with staff and themed supervisions, to ensure they 
know  how  to  add  to  the  scheduled  observations.    We  are  auditing  the  use  of  the 
systems – see below.  

In  the  event  that  a  resident  falls  or  is  found  on  the  floor,  the  electronic  recording 
provides system alerts to be set up to highlight the interactions that must be completed 
by way of a post fall assessment which includes: 

•  Pain level assessment 
•  Visual skin checks and any changes with wounds 
•  BP monitoring, heart rate monitoring and respiration monitoring 
•  Any changes to mobility.  

This  system  also  has  a  section  for  the  recording  of  notes  which  are  sent  to  the 
handover  team  to  inform  them  of  any  changes.    This  allows  for  very  effective 
communication – both written and oral updates on a service user’s status.  

The post falls observations that are on the digital system set out all the matters that 
must  be  included  such  as  details  of  the  incident,  the  resident’s  wellbeing,  and 
confirmation  that  the  detailed  observations  have  been  completed.  Therefore,  the 
events before, during and after a patient’s fall will be entirely accurate and there will 
be less opportunity for there to be gaps in a patient’s record. 

All staff have had in depth training on this digital system, and continue to have support 
sessions  from  a  Senior  General  Manager  for  the  region.  A  General  Manager  from 
another  Barchester  home  is  an  EnabLE  champion  for  the  region  and  will  be  in  the 

 
 
 
  
 
 
 
 
 
 
 home weekly for the next month providing support for the in-depth training being rolled 
out as well as drop-in sessions for the existing team who are already trained.  

These sessions so far have involved the completed supervisions for individuals around 
falls, and actions taken including the detailed documentation to be completed after a 
fall which includes: 

•  Falls diary 
•  Multifactorial falls risk assessment 
•  Moving and handling support plan review 
•  Risk  assessments  related  to  that  individual  to  be  reviewed,  healthcare 

professional records 

•  Observations (captured on post falls) 
•  Conversations with next of kin 

In addition to the training programme and support staff are provided with an added 
prompt  sheet to  support them  in  the  completion  of  documentation.  This is part  of  a 
“belt and braces” approach to training.  

As part of the continuing programme of learning the region’s EnabLE champion who 
supports the home with EnabLE will continue with the provision of drop-in sessions, 
documentation audit and will continue to monitor remotely for any  trends in learning 
needed around the digital system to ensure adherence to the actions triggered in the 
new system.  

NEWS2 Observation Records 

Our  new  digital  system  limits  any  opportunities  missing  entries  in  relation  to 
observations.  Our  observations  are  recorded  on  the  digital  system  in  a  NEWS2 
(National Early Warning Score) observation record, rather than manually written. The 
training for this has been completed in the home, and we also have oversight by the 
regional Clinical Development Nurse who supports all her homes monthly and looks 
at the system to make sure everything is recorded as it should be.  

The training statistics for the home are 100% for NEWS2 in the home which ensures 
the  accuracy,  frequency  and  consistency  of  recording  observations.  Every  Nurse, 
Senior  carer  and  Care  Practitioner  has  completed  NEWS2  training,  and  three  new 
bank nurses are in the process of completing their induction of which NEWS2 is part 
of the process. All NEWS2 training is completed on induction into the home, we have 
checked the recorded dates of NEWS2 training, and the dates have been recorded in 
the Learning Management system.  

The new care planning digital system has also been refreshed when starting this new 
system and has guidance sheets on the NEWS2 interaction attached for reference for 

 
 
 
 
 
 
 
 
 
 
 staff to access ‘at the point of care’. The training which the staff have received assures 
limited risk for observations to be absent. 

All  Senior  carers,  Care  Practitioners  and  Nurses  in  the  home  have  completed  the 
RESTORE,  NEWS2  and  Sepsis  training  and  completed  a  themed  supervision  for 
recognising  deteriorating  adults  in  their  care.  Senior  carers  attend  the  senior  care 
programme  which  contains  all  workshops  which  discuss  and  teach  over  clinical 
deterioration, observations, medication management how to safely be in charge of a 
residential community. 

Further,  lessons  learned  as  stated  above,  include  correct  moving  &  handling 
techniques.  The  falls  policy  has  been  reviewed  by  all  clinical  staff  to  ensure  that 
everyone  is  aware  of  the  policy  and  procedure  following  a  fall  (supported  by  the 
NEWS2 and RESTORE training above) therefore any need for escalation to medical 
services  following  a  patient’s  fall  will  be  abundantly  clear.  The  prompt  sheets  and 
guides created give an oversight of completion and can be checked by management, 
thereby mitigating the risk of the recording of inaccurate and irregular observations.  

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 the issue identified in 
the PFD have been mitigated in so far as possible. 

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

Yours faithfully 

Director of Nursing and Dementia