Patricia Heaviside

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 
Telephone: 03000 616161 
Email: enquiries@cqc.org.uk 

www.cqc.org.uk 

Rebecca Sutton 
HM Assistant Coroner  
Fourth Floor  
Civic Centre  
North Terrace  
Crook  
County Durham  
DL15 9ES  

Our reference: 
Your reference:

27 August 2025  

Dear HM Assistant Coroner Rebecca Sutton,  

Prevention of future death report following inquest into the death of Patricia 
Heaviside  

Thank you for sending the Care Quality Commission (CQC) a copy of the prevention 
of future deaths report issued following the sad death of Patricia Heaviside.   

We note the legal requirement upon CQC to respond to your report within 56 days, 
by 5 September 2025.   

The registered provider of Howlish Hall Residential Care Home (referred to as 
Howlish Hall hereafter) is Williams & Spenceley Limited. They have been registered 
with CQC since 1 October 2010. 

The provider’s location, Howlish Hall is located at Coundon, Bishop Auckland, 
County Durham, DL14 8ED. The provider is registered for the following regulated 
activity: accommodation for persons who require nursing or personal care. The 
provider is not permitted to provide nursing care at this location.   

On 2 July 2025 CQC began an inspection of Howlish Hall following concerns we had 
received about the service relating to the environment, staff training, fire safety, the 
departure of the registered manager and ongoing concerns from the local authority 

Page 1 of 4 

 
 
 
 
  
 
  
  
  
  
  
  
  
 about a lack of sustained improvements within the service. The inspection continued 
on 3, 9 and 11 July 2025 and found significant shortfalls at the service and identified 
several breaches of fundamental standards. We took urgent enforcement action in 
the form of imposing conditions, to ensure the immediate safety of residents until 
suitable alternative accommodation could be found. Due to the significant and 
widespread issues found during the inspection, we also issued a Notice of Proposal 
to cancel the provider’s registration.     

On 24 July 2025 CQC met with representatives from Durham County Council and 

 (provider) at Howlish Hall. During this meeting 

 indicated his 

intention to serve the local authority with a 3 month notice period and stated his 
intention was to close the home as quickly as possible, before CQC cancelled his 
registration. We worked closely with local authority colleagues, and all residents 
were moved to other care facilities by the end of the day on Friday 1 August 2025.  

Background   

On 9 October 2024 
time) submitted a notification of serious injury to CQC regarding Mrs Heaviside’s fall 
at the service on 4 October 2024. The notification did not contain any information 
regarding concerns about the care provided, so CQC closed this with no further 
action.   

 (the registered manager of Howlish Hall at the 

In light of the Regulation 28 report received from yourself, we are gathering further 
information and reviewing this incident in line with our Specific Incidents guidance.   

Matters of concern   

1.  Despite recommendations for falls prevention equipment being made by 

the Community Falls Service in August 2023, no falls prevention equipment 
was put in place by the time of the Deceased’s fall in October 2024.  

Had CQC been aware of this we could have taken action to contact the provider, but 
no such concern was shared with CQC.   

2.  Despite the social worker expressing concern about the lack of falls 

prevention equipment on 27 September 2024, no falls equipment was put in 
place prior to the Deceased’s fall on 4 October 2024.   

CQC was not aware of the social worker’s concern in this regard. CQC would expect 
a social worker to complete a safeguarding referral to the local authority’s 
safeguarding team in such circumstances. CQC is unaware whether a safeguarding 
referral was completed in this case as safeguarding referrals are not always routinely 
shared with CQC by local authorities.   

3.  Information about the Community Falls Service recommendations was not 

passed on to the family, or to social services.   

CQC would usually expect the care home management team or staff to update the 
family and the person’s social worker about such recommendations from external 

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 health professionals. We were not aware at the time that this information had not 
been passed on.   

4.  On 5 August 2024 (following a fall, but before the more significant fall on 4 
October 2024), the Deceased’s family were told by the Deputy Manager of 
Howlish Hall that the owner of Howlish Hall “probably wouldn’t want to pay 
for a sensor mat”.   

CQC did not hear the evidence at the inquest, but we accept the findings of the 
inquest. CQC would expect providers to supply sensor mats if it was appropriate for 
the individual’s assessed needs. This is an issue that the Provider would be best 
placed to answer.  

5.  I received evidence that, subsequent to the Deceased’s death, there had 

been a reluctance on the part of 
of Howlish Hall Care Home) to provide adequate resources for falls 
prevention equipment.   

 (who was believed to be the owner 

When CQC and local authority representatives met with 
24 July 2025 he stated this was untrue, sensor mats were inexpensive and there 
was always a supply of several sensor mats in the home at any given time. However, 
we accept the findings of the inquest.   

 at Howlish Hall on 

CQC expects care providers to follow the NICE guidelines on falls management 
(https://www.nice.org.uk/guidance/ng249/chapter/Recommendations#interventions-
to-reduce-the-risk-of-falls). We expect providers to take a multi-factorial approach to 
falls management which includes measures such as conducting medication reviews, 
encouraging the person to remain physically active and removing hazards from the 
environment. Whilst sensor mats are useful as an early warning system that alerts 
care staff to potential falls or movements to enable swift responses to prevent 
injuries, they do not physically prevent a person having a fall.   

During the inspection on 2, 3, 9 and 11 July 2025 and subsequent concerns shared 
with us by Durham County Council, we had significant concerns in relation to falls 
management at the service. As stated above, we took urgent action to impose 
conditions on the provider’s registration. One of the conditions included a 
requirement for the provider to take steps to safeguard people from the risk of falls, 
including confirmation that appropriate equipment was in situ and service users care 
plans reflected the level of support and equipment they required to reduce the risks 
associated with falls. 

6.  Despite it being recognised that the Deceased lacked mental capacity to 

make decisions about where she lived and was unable to keep herself safe, 
it appears that the home did not make any application for a DoLS 
assessment for the Deceased. Indeed, I received evidence that when a new 
home manager was appointed at Howlish Hall in January 2025 none of the 
residents were subject to a DoLS, despite a large number of the residents 
lacking mental capacity.  

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 We were not aware of concerns regarding a lack of application for a DoLS 
assessment for the Deceased, as this was not reported to CQC. Neither were we 
aware that a large number of residents who lacked mental capacity were not subject 
to a DoLs. Had we been aware of these concerns we would have taken action at the 
time.  

When we inspected the home in July 2025 we found several breaches of 
fundamental standards, including a breach of regulation 11 of the Health and Social 
Care Act 2008 (Regulated Activities) Regulations 2014 (need for consent). We found 
evidence the provider did not have an effective process in place to monitor DoLS 
applications, or any conditions imposed.  

Further Queries   

Should you have any further queries please contact our National Customer Service 
Centre using the details below:  

Telephone: 03000 616161 or email: enquiries@cqc.org.uk  

If your query is regarding this letter, please quote the CQC reference 

Yours sincerely,  

Deputy Director of Operations  
Network North, CQC  

Page 4 of 4

Rebecca Sutton
Assistant Coroner, County Durham and Darlington

12 September 2025

Dear Rebecca,

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS – Patricia Heaviside

We  have  reviewed  the  above  report  relating  to  the  sad  death  of  Patricia  Heaviside  and
have  responded  below  to  the  coroner’s  matters  concerns  as  outlined  in  section  5  of  the
report.

(1) Despite  recommendations  for  falls  prevention  equipment  being  made  by  the
Community Falls Service in August 2023, no falls prevention equipment was put
in place by the time of the Deceased’s fall in October 2024.

It  is  important  to  clarify  that  Durham  County  Council  was  not  directly  informed  of  the
recommendations  made  by  the  County  Durham  and  Darlington  NHS  Foundation  Trust
In  accordance  with  standard  protocol,  such
(CDDFT)  Community  Falls  Service. 
recommendations  are  communicated  solely  to  the  care  home,  which  retains  full
responsibility for reviewing, actioning, and implementing the advised measures.

The responsibility for ensuring that appropriate falls prevention equipment is sourced and
put  in  place  lies  with  care  home  management.  Care  Homes  within  County  Durham  are
expected to act upon external clinical guidance and advice to ensure that any necessary
interventions are completed in a timely and effective manner. The absence of equipment
at the time of the incident reflects a failure in the care home’s duty to follow through on the
recommendations provided by CDDFT.

Durham  County  Council’s  Strategic  Commissioning  Team  and  Practice  Improvement
Team commenced monitoring visits within the care home in September 2024, with a total
of 22 onsite monitoring visits taking place from that date until the care home closed on the
1  August  2025.  During  this  period,  Durham  County  Council’s  formal  Planning  Meeting
process  was  invoked  and  subsequently  escalated  to  the  Executive  Strategy  Meeting
process  to  address  ongoing  issues.  It  should  be  noted  that  there  have  been  multiple
changes  in care home management during the last 12 months and this lack of continuity

Adult and Health Services
Durham County Council, County Hall, Durham DH1 5UG
Main Telephone 03000 260 000

www.durham.gov.uk

 has had a detrimental impact on the quality of care provided, as key information was not
consistently  recorded  or  effectively  handed  over  between  managers  and  care  staff,
resulting in missed actions and compromised management and owner oversight.

Planning  and  Executive  Strategy  Meetings 
representation from the Care Quality Commission and other relevant partners.

to  Howlish  Hall 

in  relation 

included

In July 2025, following intensive oversight as described above, Howlish Hall issued notice
to  the  Council  that  the  care  home  would  close.  Durham  County  Council  arranged  for  a
dedicated  team of officers to manage the  transition and  closure process  with the  service
and all residents were re-assessed and moved to alternative care home provision within 7
days.

(2) Despite the social worker expressing concern about the lack of falls prevention
equipment  on  27  September  2024,  no  falls  equipment  was  put  in  place  prior  to
the Deceased’s fall on 4 October 2024.

In order to clarify the events and actions taken by Mrs Heaviside’s allocated social worker,
a summary is provided below:

On  27 September  2024,  the  allocated  social  worker  visited  Howlish  Hall  to  discuss  the
safeguarding concerns raised. During the visit, care home staff informed the social worker
that a falls detector was available on site and assured that it would be placed next to the
client’s  beds.  The  social  worker  documented  his  intention  to  undertake  an  unannounced
follow-up  visit to confirm  that the equipment had  been appropriately installed. Sadly,  Mrs
Heaviside  experienced  the  significant  fall  on  4  October  2024  before  this  follow-up  visit
could be carried out.

A  further  unannounced  visit  was  conducted  by  the  social  worker  on  22  October  2024,
following Mrs Heaviside returning to the home on 11 October. During this visit, the Deputy
Manager stated that she had not been made aware of the requirement to install the falls
equipment, as the relevant messages had not been passed onto her. When challenged on
the continued delay, the social worker was informed that care staff ‘did not have access to
the  care  home’s  finances’  and  requested  that  the  social  worker  submit  the  equipment
request in writing. The social worker advised that this was unacceptable and insisted that
the equipment be ordered immediately.

On  31  October  2024, the  social  worker  returned  to  the  care  home  to  complete  Care  Act
and  Mental  Capacity  Assessments.  During  this  visit,  it  was  identified  the  falls  equipment
had  still  not  been  put  in  place  for  Mrs  Heaviside.  Care  staff  once  again  claimed  that
previous  instructions  had  not  been  communicated.  The  social  worker  remained  on  site
until they received assurances from the Howlish Hall Care Home Manager, that equipment
was going to be ordered imminently.

A final visit was undertaken on 1 November 2024, during which the social worker records
that the equipment issues were now resolved.

This  highlights  repeated  failures  in  both  communication  and  internal  accountability  within
the care home, which contributed to unacceptable delays in implementing essential safety
measures, despite clear and ongoing intervention by the allocated social worker.

The Council has an established information sharing protocol to ensure that any concerns
or issues relating  to providers’ contractual  obligations are appropriately communicated  to

 the commissioning team by social work staff. All staff will be reminded of the importance of
adhering to this process.

(3) Information  about  the  Community  Falls  Service  recommendations  was  not

passed on to the family, or to social services.

We have reviewed this matter and can confirm that we are unable to identify any Council
records  indicating  that  the  recommendations  made  by  the  CDDFT  Community  Falls
Service on 16 August 2023, and again during June 2024, were shared with either Durham
County Council or the family by CDDFT Community Falls Team or the Care Home.

Following  enquiries  with the  CDDFT Community  Falls  Team, they have  advised that  it  is
not routine practice to share such information more widely. In light of this, the Council will
be working with our CDDFT Community Falls Teams to explore how this process can be
strengthened.  The  Council’s  aim  would  be  to  establish  a  process  whereby  any
recommendations  made  by  CDDFT  Community  Falls  Team  are  communicated
appropriately  and  in  a  timely  manner  to  relevant  parties,  including  families  and  social
services.

Additionally,  the  Council  has  been  informed  by  the  CDDFT  Community  Falls  Team  that
their  records  from  August  2023  note: “no  more  falls  have  been  reported  and  the  care
setting  has  put  all  measures  in  place.”  This  record  suggests  that,  at  that  time,  the  care
home had reported to CDDFT they had taken steps to address the concerns raised.

(4) On  5  August  2024  (following  a  fall,  but  before  the  more  significant  fall  on  4
October  2024),  the  Deceased’s  family  were  told  by  the  Deputy  Manager  of
Howlish Hall that the owner of Howlish Hall “probably wouldn’t want to pay for a
sensor mat”.

Council  records  reflect  similar  observations  or  comments  made  by  care  staff  concerning
the financial implications of purchasing the equipment. Furthermore, during a safeguarding
enquiry dated the 13 September 2024, documentation includes a reference to a comment
made  by  care  home  staff  to  a  member  of  the  CDDFT’s  Community  Therapy  Team,
indicating that Howlish Hall was ‘financially struggling to provide’.

It is important to note that Durham County Council had not received any formal notification
from  the  Care  Home  owner  regarding  financial  difficulties,  despite  our  expectations  on
Provider  transparency  on  sustainability  issues  being  communicated  to  the  market  on  a
number  of  occasions.  This  is  regularly  reiterated  at  provider  forums  etc.  The  Council
strongly  encourages  Providers  who  may  be  experiencing  financial  pressures  to  engage
with  us  directly,  so  that  constructive  dialogue  is  initiated  and,  where  necessary,
appropriate action taken.

(5) I received evidence that, subsequent to the Deceased’s death, there had been a
 (who was believed to be the owner of Howlish

reluctance on the part of 
Hall Care Home) to provide adequate resources for falls prevention equipment.

In addition to the areas highlighted in the response to point 4 above, we are not aware of
  advising  that  he  would  not  specifically  provide  resources  for  falls  prevention
equipment. During monitoring visits, Council officers noted that falls prevention equipment
was installed and operational in several resident bedrooms.

 However,  financial  sustainability  and  cash  flow  of  the  home  was  discussed  with 
during a meeting held on 6 March 2025. In this meeting, 
 was asked how the Care
Home  Manager  can  access  funds  to  source  essential  items  given  he  spends  prolonged
 advised that arrangements had been made  to
periods  of time out of the  country. 
enable  the  care  home  manager  to  have  access  to  cash  and  a  credit  card  and  it  is
documented  that 
  would  speak  to  the  current  care  home  manager  to  emphasise
that if any finances were required it was acceptable to request them. However, despite this
assurance in March 2025, these measures were not put in place until June 2025.

(6) Despite  it  being  recognised  that  the  Deceased  lacked  mental  capacity  to  make
decisions about where she lived and was unable to keep herself safe, it appears
that  the  home  did  not  make  any  application  for  a  DoLS  assessment  for  the
Deceased.  Indeed  I  received  evidence  that  when  a  new  home  manager  was
appointed at Howlish Hall in January 2025 none of the residents were subject to
a DoLS, despite a large number of the residents lacking mental capacity.

Care home providers are contractually required to maintain polices and protocols relating
to the Deprivation of Liberty Safeguards (DoLS) including mental capacity. In addition, all
staff must receive appropriate training in mental capacity to ensure compliance and uphold
best practice.

In  January  2025,  Durham  County  Council  worked  with  the  newly  appointed  manager  at
Howlish  Hall  to  ensure  that  all  necessary  DoLS  applications  were  submitted  and  any
expired authorisations were promptly renewed.

DoLS  considerations  have  been  applied  to  all  residents  who  have  transitioned  to  a  new
care home placement as part of the care home closure work for Howlish Hall.

Deprivation  of  Liberty  Safeguards  is  a  regular  agenda  item  and  discussion  point  at  our
Care  Home  Strategic  Provider  Forum  meetings,  and  we  will  continue  to  reinforce  its
importance  in  upcoming  forum  sessions.  To  strengthen  oversight,  commissioning  and
safeguarding  teams  will  work  with  the  DoLS  team  to  explore  ways  of  identifying  care
homes that currently have no active DoLS authorisations in place or where renewals may
be overdue.  This will help us highlight potential gaps and ensure timely action is taken to
proactively address any issues with the care home.

I hope this response clarifies the input of the Council and wider context relating to Howlish
Hall and  would like to thank  you for sharing the  report with us. We will work to complete
the actions set out above for DCC.

Yours faithfully

Deputy Director of Local Delivery / Head of Integrated Commissioning

To:  HMAC County Durham and Darlington 
Attn. Rebecca Sutton, assistant coroner, for the coroner area of County Durham and 
Darlington in reply to your report dates July 10th 2025 

First and foremost, I was deeply saddened by the passing of Mrs. Patricia Heaviside as dear 
each and every tenant of Howlish Hall.  

Following your report and coclusions I would like to hereby strongly reply, together with 
testimonies taken from the care home and proof that the report is inaccurate to say the least. 

As owner, I have never in almost  10 years of ownership hesitated to invest in the care home 
in any matter in general and safety of the tenants in particular, including throughout Covid 
and more. Some of the so-called facts described in the report are false and will allow me to 
pursue legal action against all involved. I strongly believe that this false report, established 
on hearsay, is one if not the biggest catalyst to the closing of Howlish Hall.  

I hereby enclose testimonies from our 

mats to prevent falls as opposed to what stated. Moreover, the 
  has 
withdrawn her first statement and stated she was mistaken and above this, we are aware 
that 

 has tempered with the sensors. 

 that the building had 12 working sensor 

 the 

Your report was done based on hearsay with
about Owner not buying Sensors Mats , while howlish Hall have the best known Digital AI 
Powered  Urgent Calling System in all the County ! without checking facts, without 
investigating further and with careless view on the actual circumstances that will lead me to 
address 
 for libel and slander,the report that was published give tailwind to very 
negative advertisements in Nationwide Media ,BBC and the Northern Echo, they used 
unauthorised Stollen photos from the home along with insult from the global public assuming 
howlish hall is” killing”  its service users, specially  the case of the late Mrs Heaviside who 
lack mental capacity , that had a snowball effect to the closing of Howlish Hall Care Home. 

 testimony 

Howlish Hall has always taken seriously the safety and well-being of his Service Users , we 
have kept on record for the CQC ,  a list of last Service Users before closing the home and a 
list showing all of them had Falling sensors and detecting material. 

on Behalf of Williams & Spenceley Ltd