Prevention of Future Deaths reports · 2025

Evelyn Chancellor

Regulation 28 report to prevent future deaths, reference 2025-0382, written 25 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report25 Jul 2025
Reference2025-0382
DeceasedEvelyn Chancellor
CoronerAndrew Walker
Coroner areaLondon (North)
CategoryCare Home Health related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

1. Ashton Lodge Care Home

1

CORONER

I am Mr Andrew Walker, senior coroner for the coroner area of Northern London

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 the 10th October 2024 I commenced an investigation into the death of, Evelyn
Chancellor, aged 91. The investigation concluded at the end of the inquest on 3rd
Jue 2025. The conclusion of the inquest was Consequences of a fall in a care.
The medical cause of death was 1a Intracranial Haemorrhage.

4

CIRCUMSTANCES OF THE DEATH

On the 4th of October 2025 Evelyn Veronica Chancellor was in a supervised
lounge in a care home when, in a moment when the person supervising the
lounge turned away to collect some cups, she fell from her chair and struck her
head. Mrs Chancellor was taken to hospital where a decision to arrange a CT
scan was considered and decided against and Mrs Chancellor was discharged
back to the care home.
Mrs Chancellor started so show symptoms of serious head injury and was
returned to hospital where she died from the consequences of the head injury the
next day.

1

 5

CORONER’S CONCERNS

During the course of the inquest the evidence 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.  –

There should be sufficient staff present to ensure the safety of the residents when
staff members are engaged in activities that may distract them from their view of
the residents.

6

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you
and 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, namely by Friday 19th September 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.

8

COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following
Interested Persons:

Family Members.

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 other 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.
DATE: 25th July 2025

9

2

Responses

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.

Response from Ashton Lodge Care Home (PDF)
Ashton Lodge Care Home 
95 The Hyde 
Colindale 
London 
NW9 6LE 

HM Coroner 
Mr Andrew Walker 

Date: 16/09/2025 

Dear Mr Andrew Walker, 

Re: Response to Regulation 28 Report to Prevent Future Deaths 

Thank you for the opportunity to respond to the Regulation 28 Report to Prevent Future 
Deaths, issued following the inquest into the death of Mrs Evelyn Chancellor. 
First and foremost, I would like to extend again our sincere condolences to Mrs Chancellor’s 
family. At Ashton Lodge, we are fully committed to learning from all incidents and ensuring 
the highest possible standards of safety and care for our residents. 

1. Resident Supervision at the Time of the Incident 

At Ashton Lodge, we are committed to delivering safe, compassionate, and person-centred 
care, including appropriate supervision in communal areas.  
On the day in question, Mrs Chancellor was in the main lounge with five to six other 
residents. A member of staff was present in the lounge and providing active supervision. 
The staff member remained in the same room at all times but briefly turned their attention 
to prepare a drink for another resident; an essential care task carried out while remaining in 
the same room and maintaining general oversight of the environment. This momentary 
redirection of focus reflects the normal operational demands of communal care settings, 
where staff are required to respond to the needs of multiple residents simultaneously. 
We would like to respectfully clarify that this was not a case of absent supervision. Rather, it 
reflects the nature of communal care environments, where staff are often required to meet 
the simultaneous needs of multiple residents. While we strive to maintain visibility of all 
residents at all times, it is not operationally or clinically feasible to provide uninterrupted 
one-to-one supervision for every individual unless a formal risk assessment and funding 
arrangement (e.g., CHC- Continuing Healthcare) has identified such a need. 
At the time of the incident, Mrs Chancellor was not assessed as requiring 1:1 supervision. 

Lukka Care Homes (2010) Limited – Company Registration No:  7247902 

 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   Ashton Lodge Care Home 
95 The Hyde 
Colindale 
London 
NW9 6LE 
TEL: 0208 732 7260 
FAX: 0208 732 7269 
ashtonlodge@lukkahomes.com 

2. Supervision – Clinical and Operational Context 

In communal areas where residents have not been assessed as requiring one-to-one 
supervision, it is considered safe and appropriate for staff to engage in routine tasks such as 
preparing refreshments, while maintaining general oversight of the environment. 
As discussed during the inquest, constant 1:1 supervision for all residents in communal 
areas is not the standard practice in residential or nursing home settings. 
Staffing at Ashton Lodge follows safe practice standards and risk-based frameworks, 
including maintaining appropriate staff-to-resident ratios. On the day of the incident, the 
numbers of members of staff was sufficient.  

3. Governance and Preventative Measures 

At Ashton Lodge, we are fully committed to providing safe, high-quality care through 
proactive, evidence-based practice. Falls prevention is a key component of this approach, 
and we have consistently implemented comprehensive measures to assess, manage, and 
reduce risk for all residents. This includes regular multifactorial risk assessments, 
personalised care planning, environmental adaptations, and staff training—all aligned with 
national guidance and regulatory standards. 
While the risk of falls can never be entirely eliminated in a frail, elderly population, it can be 
responsibly managed and mitigated through evidence-based practice, an approach we have 
consistently taken at Ashton Lodge. 
Ashton Lodge operates within a robust governance framework to reduce the risk of falls and 
ensure timely responses to residents' needs. This includes: 

  Comprehensive falls risk assessments on admission and routinely thereafter 

  Mandatory staff training on falls prevention and response 

  Daily environmental safety checks 

  Use of assistive technology as appropriate 

 

Immediate post-fall reviews and MDT (Multidisciplinary Team) debriefs 

  Monthly falls governance meetings to analyse incident trends and adapt protocols 

accordingly 

Lukka Care Homes (2010) Limited – Company Registration No:  7247902 

 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   Ashton Lodge Care Home 
95 The Hyde 
Colindale 
London 
NW9 6LE 

Following this incident, we have implemented additional steps to further reduce risks: 

  Reinforced staff awareness on maintaining visual oversight during minor tasks (e.g., 

preparing drinks) 

  Adjusted staff routines to enhance monitoring during peak communal area usage 

  Reviewed staff deployment to optimise visibility and supervision in shared spaces 

  Provide targeted refresher training on falls prevention and shared-space supervision. 

4. Medical Cause of Death – Clinical Clarification 

We feel, in hindsight, that the hospital could have investigated Mrs Chancellor’s head injury 
more thoroughly before discharging her back to the care home. Following her fall, we noted 
that she was returned to us without what appeared to be a full investigation of the injury, 
despite the associated risks given her multiple comorbidities, severe frailty, anticoagulant 
therapy, and the fact that she was receiving end-of-life care. 
The hospital informed the nursing home that Mrs Chancellor was well and discharged her 
without further investigation or consultation with the family or the care home. The 
deterioration in her condition was only identified later. Despite stating that surgery was not 
possible, the hospital did not involve the family or the nursing home in the decision-making 
process. Furthermore, the nurse in charge was informed that an X-ray would be conducted 
prior to her first discharge, which did not occur.  
We also respectfully note the conclusion in the inquest findings that the death was “caused 
by a fall in a care home.” 
While it is undisputed that Mrs Chancellor experienced a fall, as previously mentioned, she 
was a clinically frail individual, with multiple comorbidities, receiving end-of-life care and 
was on anticoagulant medication. Following her readmission to hospital, a CT scan revealed 
an intracranial bleed. However, evidence presented during the inquest highlighted that the 
fall was of very low impact and that Mrs Chancellor appeared clinically well after her initial 
hospital attendance. It was noted that an individual without her level of frailty and complex 
comorbidities would likely have survived such a minor fall. Her subsequent deterioration 
and death were considered to be the result of her overall clinical condition, rather than the 
fall alone. The intracranial haemorrhage must also be understood within the context of her 
severe frailty, multiple comorbidities, and anticoagulant therapy. 
It was the expert opinion that her death should be viewed as resulting from natural causes, 
due to a complex interplay of clinical vulnerabilities rather than trauma alone. 

Lukka Care Homes (2010) Limited – Company Registration No:  7247902 

 
   
 
 
 
 
 
 
 
 
 
 
 
 
   Ashton Lodge Care Home 
95 The Hyde 
Colindale 
London 
NW9 6LE 

5. Conclusion 

We support the intent behind Regulation 28 and are fully committed to continuous 
improvement. We have taken this case extremely seriously and have acted swiftly to 
strengthen staff awareness, review risk protocols, and optimise supervision strategies. 
We are always open to further dialogue or review, and we remain focused on delivering 
safe, person-centred, and dignified care to all residents at Ashton Lodge. 

6. Action Plan in Response to the Regulation 28 Report 

In direct response to the concern raised regarding staff supervision in communal areas, 
Ashton Lodge has developed the following action plan to enhance clinical oversight and 
minimise the risk of future incidents: 

Action 

Description 

Responsible 

Timeframe 

Status 

1. Install 
Nurses’ 
Stations in 
Lounges 

2. Lounge 
Supervision 
Protocol 

Introduce fixed Nurses 
stations in main 
communal lounges to 
enhance clinical 
presence and oversight. 
This will allow nurses to 
carry out administrative 
or clinical 
documentation while 
maintaining continuous 
visual supervision of 
residents. 

Develop and implement 
a formal protocol for 
staff working in 
communal areas to 
ensure visibility is 
prioritised during all 
tasks, including brief 
diversions (e.g., 

By 30 
October 
2025 

Under 
Implementation 

Registered 
Manager / 
Operations 
Manager/ 
Director 

Implemented 

Clinical Lead / 
Clinical Head 
of Care 

Effective 
from 1 
August 
2025 

Lukka Care Homes (2010) Limited – Company Registration No:  7247902 

 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
   Ashton Lodge Care Home 
95 The Hyde 
Colindale 
London 
NW9 6LE 

Action 

Description 

Responsible 

Timeframe 

Status 

preparing drinks). 
Protocol will include 
“eyes-up” guidance, 
strategic positioning, 
and handover 
awareness. 

Introduce a structured 
rota to assign an 
additional staff member 
to lounges during peak 
activity times (e.g., after 
meals, afternoon 
activities), when 
distraction risk is higher. 

Provide targeted 
refresher training on 
falls prevention and 
shared-space 
supervision. This will 
emphasise balancing 
multiple residents’ 
needs while maintaining 
safe monitoring 
practices. 

Introduce short daily 
team briefings, during 
staff handover to 
reinforce awareness of 
high-risk residents and 
key monitoring 
expectations in 

3. Enhanced 
Supervision 
During Peak 
Times 

4. Staff Training 
Refresher 

5. Daily 
Supervision 
Briefings 

Implemented 

Clinical Lead / 
Clinical Head 
of Care 

Effective 
from 1 
August 
2025 

Implemented 

Registered 
Manager/ 
Clinical Lead / 
Clinical Head 
of Care 

Effective 
from 9, 12, 
13, 15 of 
May 2025 

Implemented 

Clinical Lead / 
Clinical Head 
of Care/ Shift 
Leaders 

Effective 
from 9 of 
May 2025 

Lukka Care Homes (2010) Limited – Company Registration No:  7247902 

 
   
 
 
 
 
 
 
 
 
   Ashton Lodge Care Home 
95 The Hyde 
Colindale 
London 
NW9 6LE 

Action 

Description 

Responsible 

Timeframe 

Status 

6. 
Environmental 
Risk Review 

communal areas. 

Conduct a full review of 
communal area layouts 
to reduce blind spots, 
improve sightlines, and 
support supervision 
strategies. 

H&S Lead / 
Registered 
Manager/ 
Clinical Lead/ 
Clinical Head 
of Care 

By 30 
September 
2025 

Under 
Implementation 

Monitoring and Audit 

We will monitor the effectiveness of the above actions through: 
  Weekly clinical walkarounds by the management team 

  Monthly supervision audits in communal areas 

  Monthly falls governance meetings to analyse incident trends and adapt protocols 

accordingly 

This action plan will be reviewed internally every three months and shared with external 
professionals upon request, to ensure accountability and transparency. 

Thank you once again for the opportunity to respond. 

Yours sincerely, 

Registered Manager 
Ashton Lodge Nursing Home 

Lukka Care Homes (2010) Limited – Company Registration No:  7247902

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