Valerie Hill

Criminal Procedure Rules 2010 r27.1; Criminal Justice Act 1967, s9 Magistrates Courts Act 1980, s5A and s5B)

IN THE MAJESTY’S CORONERS’ COURT S.WALES CENTRAL 
CORONER AREA

BEFORE SENIOR CORONER MR GRAEME HUGHES

SITTING IN PONTYPRIDD CORONERS’ COURT

TOUCHING UPON THE DEATH OF 
VALERIE HILL

SECOND WITNESS STATEMENT OF 

AGE OF WITNESS : OVER 18

OCCUPATION : PRINCIPAL MANAGER FOR ADULT SERVICE PROVISION

This  Statement  consisting  of  6  pages  each  signed  by  me  is  true  to  the  best  of  my 

knowledge and belief and I make it knowing that, if it is tendered in evidence, I shall 

be liable to prosecution if I have wilfully stated in it anything which I know to be false 

or do not believe to be true. 

Dated: 03/09/2025 

I 

 of Merthyr Tydfil County Borough Council, County Hall, 

Merthyr Tydfil County Borough Council, County Hall, Merthyr Tydfil 

WILL STATE :-

1.

I am employed by Merthyr Tydfil County Borough Council (“Merthyr Council”) 

as  a  Principal  Manager  for  Adult  Services.  I  refer  to  my  earlier  witness 

statement  in  this  matter  dated  23  May  2025.  This  is  my  second  witness 

statement in this matter, and it relates to HM Senior Coroner’s Regulation 28 

Prevention  of  Future  Deaths  Report  (“PFD  Report”)  issued  in  regard  to  this 

inquest dated 13 June 2025, received by the solicitors instructed on behalf of 

Merthyr Council on 17 June 2025. 

 
 2.

I have received a copy of HM Coroner’s PFD Report, and I have considered 

the  same  and  the  concerns  raised  in  some  detail.  As  will  be  seen  from  the 

later  paragraphs  of  this  statement,  a  number  of  steps  have  been  taken  by 

Merthyr  Council  to  specifically  address  HM  Senior  Coroner’s  concerns,  it  is 

due  to  the  complexity  of  some  of  those  steps  that  this  response  was  not 

capable of being provided within the initial timeframe provided by HM Senior 

Coroner. 

3. Dealing, firstly, with HM Senior Coroner’s concerns as to assessment of falls 

risk (paragraphs (1) – (5) of the PFD Report), the concerns expressed by HM 

Senior  Coroner,  in  summary,  are  to  the  effect  that  Merthyr  Council  had  not 

applied its mind to the management of falls risk in the context of care home 

residents,  as  distinct  from  steps  to  be  taken  to  deal  with  falls,  the  same 

having taken place. 

4. As addressed in my first statement, Merthyr Council relied upon the All Wales 

NHS Manual Handling Passport Scheme (the “All Wales NHS Scheme”) and 

the  documentation  and  training  within  that  scheme.  This  scheme  is  utilised, 

based on this form, I understand, by the 22 unitary local authorities in Wales. 

5. Consequent upon the concerns of HM Senior Coroner, however, a number of 

new documents have now been drafted and have recently been implemented 

by  Merthyr  Council  in  the  context  of  addressing  these  concerns,  moving 

forwards. 

6. Firstly, an 8 page detailed guidance document for staff on the Prevention and 

Management of Falls has been developed. As above, one of the issues (if not 

the  central  issue  identified  by  HM  Senior  Coroner  in  paragraphs  (1)  –  (5)  of 

his PFD Report) was the perceived lack of a distinct Falls Prevention Strategy 

or  Policy.  The  Council,  through  myself,  has  taken  on  board  HM  Senior 

Coroner’s  comments  and,  as  above,  has  now  developed  this  guidance  for 

staff  directed,  as  far  as  reasonably  practicable,  to  the  prevention  and 

management of falls in a residential care home setting. 

Dated:  03/09/2025

 
     
 7. A  copy  of  the  latest  version  of  this  Prevention  and  Management  of  Falls 

guidance document for staff is attached to this witness statement marked “KL 

6”. 

8. As  part  of  the  implementation  of  this  new  guidance,  the  Council,  through 

myself, and in consultation with the Council’s Health and Safety Department, 

has  also  developed  a  new  (9  page)  Multifactorial  Falls  Risk  Assessment 

document to be used regarding relevant users of adult services. A copy of this 

Multifactorial  Falls  Risk  Assessment  document  is  attached  to  this  witness 

statement marked “KL 7”. 

9. Additionally,  a  Post  Fall  Summary  document  has  also  been  developed  as  a 

means  of  review  and  evaluation  of  any  falls  sustained  by  care  home 

residents,  to  further  understand  and  review  risk  in  general  on  an  ongoing 

basis. A copy of this document is attached to this witness statement marked 

“KL 8”. 

10. Further, and again in response to HM Senior Coroner’s concerns in his PFD 

Report,  the  Council  has  revisited  the  issue  of  moving  and  handing  plans  for 

residential care home occupants. The council has now amended its approach 

to  such  plans,  such  that  they  can  now  only  be  completed  by  appropriate 

senior  members  of  staff  (care  home  managers,  care  home  assistant 

managers and senior carers). Once completed – in any event – these moving 

and  handling plans  now  must  be  reviewed and  signed  off  by the  care  home 

manager  or  assistant  manager.  Staff  undertaking  this  process  will  receive 

specific  training  (see  below)  –  this  is  in  addition  to  the  training  I  identified  in 

my first witness statement herein. 

11. As part of this process, a new Moving and Handling Risk Assessment Form 

has  also  been  developed  and  a  copy  of  that  new  form  is  attached  to  this 

witness  statement  as  “KL  9”.  It  is  anticipated  that  this  new  approach  to  the 

moving  and  handling  plan  will  ensure  that  this  document  is  a  “living 

document”  –  that  is  to  say  –  it  is  continually  informed  and  reviewed  by 

Dated:  03/09/2025

 
     
 reference  to  the  Falls  Prevention  and  Management  Guidance,  by  means  of 

update by documents including the Post Fall Summary and Multifactorial Falls 

Assessment. 

12. Training as to the completion of the Moving and Handling Risk Assessment(s) 

has  been  provided  to  Care  Home  and  Adult  Services  Managers  by  the 

Council’s dedicated adult services manual handling trainer. Further training as 

to  this  was  provided  to  Senior  Carers  and  Assistant  Managers.  Once  the 

Council’s  Trainer  is  satisfied  that  all  these  staff  are  to  be  regarded  as 

competent to carry out such reviews and the drafting of moving and handling 

plans, they will be permitted to do so, but not before this point in time. This is 

something  of  an  ongoing  process,  but  it  is  designed,  rather  obviously,  to 

address HM Coroner’s concerns and will seek to do so. 

13. There  will  be  additional  training  as  to  the  newly  created  Prevention  and 

Management  of  Falls  Guidance, 

the  Multifactorial  Falls  Assessment 

document  and  the  Post  Fall  Summary  document.  Once  again,  this  is  an 

ongoing  process,  but  there  is  a  meeting  arranged  on  Friday  5th  September 

with  the  Council’s  Health  and  Safety  officer  and  Manual  Handling  trainer  to 

discuss the development of this training programme.

14. Feedback  on  this  new  suite  of  documents  has  been  sought  from  Care 

Inspectorate Wales (CIW) who are the relevant Regulator for Care Homes in 

Wales,  and  this  has  been  positive.  However,  the  documents  were  only 

finalised at the end of July 2025 and therefore it will be necessary to further 

interact with CIW as to the same, during the process of further inspections of 

care homes, following their implementation. 

15. It  would  be  fair  to  say  that  Merthyr  Council  has  fully  taken  on  board  HM 

Coroner’s  concerns  around  policy  documents  and  developed  –  from  the 

ground  up  –  suitable  guidance  documents  addressing  HM  Senior  Coroner’s 

Concerns.  Lying  behind  those  additional  policy  documents  is  (see  above) 

further training to implement these new systems. In that sense, therefore, this 

Dated:  03/09/2025

 
     
 remains  something  of  an  ongoing  process  but  hopefully  HM  Senior  Coroner 

will see the progress and efforts which have been made to address the risks 

he has identified. 

16. There were 2 further elements to the PFD Report from HM Coroner. 

17. Firstly,  at  paragraph  (4)  HM  Senior  Coroner  identified  that  the  risk 

assessment forms – according to the All Wales NHS Scheme documentation 

provided  in  my  initial  statement  –  required  to  be  signed  off  by  a  Registered 

Healthcare  Professional.  It  will  be  understood  by  HM  Coroner  that  this 

documentation was developed, primarily, by the NHS in Wales for use in NHS 

settings,  with  regard  to  the  moving  and  handling  of  NHS  patients.  The 

availability  of  Registered  Healthcare  Professionals  in  those  settings  is 

obvious.  In  a  local  authority  residential  care  home  environment,  registered 

medical healthcare professionals of this type are never routinely available and 

the “requirement” for sign off of risk assessments by such persons is actually 

a  vestige  from  the  original  environment  in  which  these  documents  were 

developed (see above). 

18. However, to address the underlying concern by HM Coroner, presumably, as 

to review and counter-signature of relevant documents – this is why Merthyr 

Council (see above) has introduced the aforementioned process of a counter-

signature  on  relevant  manual  handling  plans  by  a  care  home  manager  or 

assistant manager. 

19. Secondly,  HM  Senior  Coroner  wished  to  receive  some  further  clarity  as  to 

what actions Merthyr Council’s Health and Safety Department take in regard 

to falls notifications. This is referenced at paragraph (6) of his PFD Report. 

20. I have discussed this with 

 the Health and Safety Manager of 

Merthyr Council. 

21.

 advises me that when a report of a fall in a residential care home 

is  provided  to  the  Health  and  Safety  Department  –  as  it  would  routinely  be 

Dated:  03/09/2025

 
     
 when  a  care  home  resident  sustained  a  fall  in  the  care  home  setting  (such 

reports  being  copied  to  the  Health  and  Safety  Department)  –  the  report  is 

reviewed  by  one  of  the  health  and  safety  team  who  would  be  specifically 

looking 

for  any  “environmental” 

features  which  may  require 

further 

investigation. That is to say – they would be examining the report specifically 

to  identify  if  there  is  any  suggestion  contained  therein,  that  any  issue  within 

the  care  home  environment  was  possibly  contributory  to  the  incident  –  so  – 

for instance – they would look for example for any references to floor defects 

or carpet defects in the context of the fall. 

22. On  the  assumption  that  such  an  issue  was  identified  within  the  reporting 

documentation  –  the  health  and  safety  team  would  contact  the  care  home, 

which may include a visit to the care home in question to further investigate 

and,  if  necessary,  make  recommendations.  Those  recommendations  would 

be reported into the care home manager, and I would also be notified of the 

situation. 

23. The health and safety team would also be looking for any trends in regard to 

falls  or  concerns  relating  to  that  aspect  –  which  –  if  they  arose  –  would  be 

reported back to the Adult Social Care Management Team – likely via myself. 

24. The  (ever  present)  falls  risk  associated  with  elderly  persons  in  a  care  home 

setting is primarily the focus of Adult Social Care and needs to be addressed 

via individual care plans (through Social Services) and moving and handling 

plans  (developed  on  site  –  see  above),  based  on  appropriate  risk 

assessments.  The  health  and  safety  team’s  principal  involvement  should  be 

to ensure that if there is an underlying environmental or other particular risk, it 

is picked up and addressed. Despite the best staff and care, there will be falls 

from time to time – this is a recognised feature of the care of older and frail 

persons. 

Dated:  03/09/2025