Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0309, written 18 Jun 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Jun 2025 |
|---|---|
| Reference | 2025-0309 |
| Deceased | Margaret Douglas |
| Coroner | Charlotte Keighley |
| Coroner area | Cheshire |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Holcroft Grange 2 Minster Care Group 3 1st Care 4U 1 CORONER I am Charlotte KEIGHLEY, Assistant Coroner for the coroner area of Cheshire 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 07 October 2024 I commenced an investigation into the death of Margaret Elizabeth DOUGLAS aged 82. The investigation concluded at the end of the inquest on 04 June 2025. The conclusion of the inquest was that Margaret Elizabeth Douglas died as a consequence of naturally occurring disease, contributed to by injuries sustained as a result of recurrent falls. It has not been possible to determine whether, on the balance of probabilities, an acute event occurred in the period immediately prior to her death which contributed to it. 4 CIRCUMSTANCES OF THE DEATH On the 1st June 2024, Margaret Elizabeth Douglas had an unwitnessed fall at home, having suffered a minor stroke and was noted to be experiencing increased confusion, slurred speech and difficulties mobilising. Following a period of rehabilitation in Hospital, Elizabeth was admitted to the Heathside Assessment Pathway service to support her recovery and was assessed by the Speech and Language Therapy team as requiring level 2 fluids as she was at risk of aspiration. Whilst at Heathside, Elizabeth suffered two falls, one of which caused a small bleed on her brain which was not identified on imaging at the time. Elizabeth was discharged home with a package of care but was unable to cope because of her risk of falls. On the 22nd August 2024, Elizabeth was moved to Holcroft Grange where her risk of falls was identified as high and she suffered a number of further falls, leading to a decline in her condition, an increase in the size of her subdural haemorrhage, worsening stroke symptoms with her becoming increasingly frail and at increased risk of aspiration. By the 5th September 2024, Holcroft Grange had identified that the were no longer able to meet Elizabeth’s needs, considering that she required one to one care, however, they accepted her back without one to one care, following which, she suffered a further fall, causing injury to her face. A condition of Elizabeth’s discharge was that one to one care would be provided, which Holcroft Grange outsourced to a care agency. In the days which followed, Elizbeth’s condition deteriorated with a worsening of her stroke symptoms and a developing chest infection with a ceiling of care being put in place for her to remain at Holcroft Grange with input from primary care services. Regulation 28 – After Inquest Document Template Updated 30/07/2021 On the 28th September 2024, it was noted that there had been a further deterioration in Elizabeth’s condition, as she was unable to hold her head up and had been unsettled and often screaming. Staff advised that she should be cared for in bed, but no medical advice was sought and consequently the deterioration in her condition was not assessed with no consideration of symptom management or whether she had reached a point whereby she required end of life care. Overnight on the 29th September 2024, Elizabeth was unsettled and the carer who took over her care the following morning was unable to understand what had occurred overnight or communicate successfully to assess Elizabeth’s needs. That morning, Elizabeth was provided with a drink, although it has not been possible to say whether at the time, Elizabeth was positioned correctly to avoid her risk of aspiration. Soon afterwards, Elizabeth was laid down, stopped breathing and passed away. Given the ambiguity of the evidence provided at Inquest, it has not been possible to determine whether an acute event occurred at that time which contributed to Elizabeth’s death. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) i) In the course of the Inquest I heard evidence that by the 5th September 2024, Holcroft Grange had already identified that they were unable to meet Elizabeth's needs, considering that she required one to one care. Despite being aware that they were unable to meet Elizabeth's needs and that they were unable to provide one to one care, Holcroft Grange accepted Elizabeth back into their care, following which she suffered a further fall. Agreeing to provide care for an individual in circumstances where it is known that the level of care that person requires to keep them safe cannot be provided, creates a risk that future deaths could occur as a consequence of inadequate care and supervision. In the course of the Inquest I heard evidence from the individual who was caring ii) for Elizabeth on the morning of her death and in the course of that evidence it became apparent that the carer had little understanding of Elizabeth’s needs and had difficulty communicating and understanding information in English. The evidence given by those at Holcroft Grange was that they outsourced the provision of the one to one carers to a company, '1st Care 4 U Ltd' who had been approved for use by their parent company 'Minster Care Group'. At the time the care was provided, it was known by those responsible for sourcing the care, that there were difficulties with Elizabeth’s communication and her complex needs. This evidence gives rise to significant concerns in respect of the ability of those providing one to one care to understand an individual’s complex needs and their ability to communicate with those who themselves have difficulties with their speech. The concerns were heightened in the context of this case given that Elizabeth was at high risk of aspiration and if carers are unable to understand the complexities of an individual’s needs and communicate effectively with them, it poses a risk to their life. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, Regulation 28 – After Inquest Document Template Updated 30/07/2021 namely by August 13, 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to CQC Inquest Reports who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 18/06/2025 Charlotte KEIGHLEY Assistant Coroner for Cheshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
12th August 2025. Prevention of Future Deaths Report Response -Margaret Elizabeth Douglas (Elizabeth) Dear Madam This is a response to the Prevention of Future Deaths report made following the inquest touching the death of Margaret Elizabeth Douglas (referred to throughout as Elizabeth) and the “Matters of Concern” raised within your findings. . I am a director of Minster Care Management Ltd, the parent company of My name is Holcroft Grange and also registered NI for Holcroft Grange. I am a registered nurse (Mental Health) with the Nursing Midwifery Council - Practice degree in Community Mental Health Nursing (older person). I have operated in health care since January 2001 and as a registered nurse since 2005. - and hold an additional Specialist May I first take this opportunity to offer my sympathies to the family of Elizabeth for the loss of their loved one during her stay with Holcroft Grange. I write to inform you of the actions taken in response to this report and provide reassurance regarding the concerns raised. I note in court, that the local authority stated that as a provider we could have put a 1-1 in place and then claimed back the monies later down the line. However, this suggestion is just not my experience or our company’s experience of working with local authorities and I can highlight several cases whereby we are pursuing funds for such cases via the courts. In response conclusion to point i of the Regulation 28 Report, which read as follows: “in the course of the inquest I heard evidence that by 05 September 2024 Holcroft Grange had already identified that they were unable to meet Elizabeth’s needs, considering that she required one to one care. Despite being aware that they were unable to meet Elizabeth’s needs and that they were unable to provide one to one care, Holcroft Grane accepted Elizabeth back into their care, following which she suffered a further fall. Agreeing to provide care for an individual in circumstances where it is known that the level of care that person requires to keep them safe cannot be provided, creates a risk that future deaths could occur as a consequence of inadequate care and supervision. We understand that costs should not be a factor which determines the necessity of providing 1-1 care. Within the Croftwood Care portfolio of homes, any manager can contact me to seek support with navigating the difficulties in securing funding for clients such as Elizabeth. Within our group of homes, we also have a clinical nurse who assists with ensuring that we meet the care needs of any residents who may have more complex presentations. We have made the further organisational changes in order to further embed this working practice: 1) All managers will be reminded of the need to communicate any difficulties they may have in managing a client with complex needs, to their area managers and then subsequently to our clinical nurse, Siobhan Christie, and/or myself. This also will include a specific agenda item being included in manager’s supervision checklists, circular communications and additional training. 2) By September 2025, all managers will have received “escalation” training directly from Area Managers. This will ensure they are able to confidently raise concerns directly to the Local Authority in cases where clients have been placed inappropriately or where the client’s needs rapidly become more complex. This training will be part of the induction process and then as part of annual supervision. This will also then be written in to our escalations policy. 3) The organisation has reminded all managers (via email) that should 1-1 care be required, but refused by the third party (usually a local authority), this refusal should be escalated to our Head Office and oversight team for assistance &support to resolve the issue. This matter will then be taken up by our Operations Team to ensure that the 1-1 care is assessed further and then provided until funding from the Local Authority can be secured. This will ensure that appropriate levels of care provided while we await a substantive response from the Local Authority (or other relevant third-party organisation). We plan to do this by utilising our own workforce in the interim period. Should the funding not then be forthcoming and any requests for assistance be refused, a notice will be served to the Local Authority for the resident to leave the home. In response to point ii of the Regulation 28 report which reads as follows: “In the course of the Inquest I heard evidence from the individual who was caring for Elizabeth on the morning of her death and in the course of that evidence it became apparent that the carer had little understanding of Elizabeth’s needs and had difficulty communicating and understanding information in English. The evidence given by those at Holcroft Grange was that they outsourced the provision of the one-to-one carers to a company, '1st Care 4 U Ltd' who had been approved for use by their parent company 'Minster Care Group'. At the time the care was provided, it was known by those responsible for sourcing the care, that there were difficulties with Elizabeth’s communication and her complex needs. This evidence gives rise to significant concerns in respect of the ability of those providing one to one care to understand an individual’s complex needs and their ability to communicate with those who themselves have difficulties with their speech. The concerns were heightened in the context of this case given that Elizabeth was at high risk of aspiration and if carers are unable to understand the complexities of an individual’s needs and communicate effectively with them, it poses a risk to their life.” In order to ensure that any staff engaged by Holcroft Grange have an appropriate understanding of residents’ care needs, we ensure that they have completed the International English Language Test (IELTS) exam. This forms part of our introductory checklists and paperwork prior to staff members working on our premises. Further, we have made the following improvements across our service Actions: 1) Our organisation will ensure that all overseas workers that attend our services via agencies have a competent understanding of the English language, both spoken and written. This will now be assessed by the person in charge of each shift to ensure that the command of the English language is good. Where it is deemed “inadequate” the staff member will not be allowed to work on site. 2) Our induction policy for agency workers will now form part of our compliance test undertaken by our routine internal monitoring teams. A monthly audit is carried out by area managers and the induction policy for agency workers will form a specific section within the audit documentation. This will provide assurances to our monitoring team that all agency staff have had sufficient opportunity to engage and read the relevant care plans for each resident they are caring for. Each agency carer will also have an induction through their own agency, before they are given an induction to the site and to the residents to be cared for, which will include time allocated to read specific care plans. 3) Handover of care between staff will be enhanced to ensure that any irregular staff ie Agency carers, have a written description of the issues and conditions that a person may exhibit. In addition to verbal handovers from the relevant staff members, written descriptions of the care plans will now be provided at the start of the shift. Information contained in the handover is also provided on handheld electronic devices that are given to all staff, and this information can also be easily updated at any given time. If you require any further information regarding any of the actions described above, please do let me know and I will be happy to assist. Yours sincerely Operations Director
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