Marion Jones

care UK

Connaught House

Mr Benjamin Myers

i 850 The Crescent
HM Assistant Coroner Colchester Business Park
Colchester
Coroner's Court Essex
C04 90B

1 Mount Tabor Street Tel 0300 130 3030

careuk.com
Stockport

SK1 3AG

By email only to coroners.office@stockport.qov.uk

2 October 2025

Dear Mr Myers,
Response to the Regulation 28 report in the Marion Jones inquest

We write in response to your Prevention of Future Deaths report (PFD) issued on 7 August 2025
following Mrs Jones’s Inquest. Your letter was addressed to Mr Andrew Knight, the Chief Executive
Officer of Care UK, who asked me to carry out a thorough investigation before formally responding.

| am a Solicitor having qualified in 1996. | joined Care UK in October 2007 to set-up the legal function
and have run it since then. One of my responsibilities is the oversight of any Coroners’ Inquests that
Care UK is involved with.

At Care UK we take any Prevention of Future Deaths report very seriously and we appreciate the
Opportunity to look into the concerns outlined in your report.

The investigation has involved Danielle Whittaker, the Home Manager of Riverside care home; Dave
Ankers, the Regional Director who manages Danielle; Jo Crossland, the Head of Nursing, Care and
Dementia; Phil Clarke, the Head of Health & Safety; James Frewin, Head of Regulatory Governance and
Rachel Harvey, the Director of Care, Quality and governance who also manages Jo, Phil and James.

We will address each of your concerns separately:

Bed Rails

You raised a concern regarding the lack of assessment for bed rails for Marion Jones in paragraphs 1, 2
and 3 of your report:

“1. No pre-admission assessment for bed rails was recorded by the staff
member responsible from Riverside, and this does not appear to have taken
place.

This is in circumstances where bed rails were already in place at Willow Wood
and where there were obvious and recorded difficulties with regard to
movement in and about bed, in addition to physical activity more generally.

Care UX Care Services Limited. Registered in England. Registration Number. 02571516
Registered office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester. Essex CO4 908

Given the circumstances, a pre-admission assessment for bed rails should have
taken place and/ or been recorded.

2. The inquest heard that family members raised their concerns on
admission of Marion Jones to Riverside when they saw there were no bed rails.
They were assured that an assessment would take place. This did not happen
it should have done.

3. The manager of the care home agreed that in all the circumstances,
including the concerns of the family, such an assessment should have taken
place.”

It is Care UK policy that where residents are assessed or present as being at risk of falling out of bed, the
use of bed rails should be considered. In Marion’s case, the pre-admission assessment did not identify
a risk of falling out of bed that would have triggered the bed rails assessment. However, Marion had
bed rails in her previous placement and upon admission her family raised concerns regarding bed rails.
In those circumstances, Danielle agreed that a bed rail assessment should have taken place. In order to
prevent this happening again in the future, we have made the following changes outlined below:

A. Pre-admission assessment

The Care UK pre-admission assessment proforma has been updated. This will ensure that colleagues
assessing care needs for potential residents in any of our care homes are prompted to complete a bed
rail assessment. These changes are the following:

a) Under the 'Sleeping' section:

i) We have included the information regarding any history of falls.
ii) A tick box was added to indicate the use of any equipment at the time of the assessment.

b) Under the ’Moving and Positioning’ section:

i) Aphrase has been added ‘for bed rails — see Sleeping section’

c) Before the Home Manager's signature, a phrase has been added to clearly outline that the
Home Manager confirms that the form has been filled out in full with no gaps, any reasons
provided for any unavailable information, and that they believe that the care home can support
the resident’s needs.

These changes will guide our colleagues to consider a bed rails assessment on two occasions: when
assessing sleeping needs and then moving and handling needs. Additionally, Home Managers will ensure
completion of all the entries prior to signing the assessment.

B. Admission check-list form

Once the resident is admitted into our care, colleagues will complete a number of assessments in order
to plan the care we will provide. These assessments are reviewed on a monthly basis or even sooner if
there are any changes to their needs. Our admission checklist ensures that all the relevant assessments
are completed post admission as it includes a list of the assessments and the timeframe for compliance.
Previously, the checklist had a prompt for the Multifactorial Falls Risk Assessment (MFRA) to be
completed within 6 hours post admission. Now we have revised the prompts and improved the checklist
to support colleagues completing the admission process in a timely manner. These are the changes
included in the new checklist:

a. all initialisations have been expanded to include the full wording and the initialisation. This
will provide clarity on which assessment must be completed.

b. anew section has been added under the falls assessment to explain that a risk assessment
must be completed to confirm if bed rails/fall out (crash) mat/sensor mats are required, and
to consider any history of falls within 6 hours of admission. This inclusion will give our
colleagues another opportunity to consider whether bed rails or fall out (crash) mats are
required post admission.

c. The layout of this document has also been re-formatted from portrait to landscape to allow
for extra space; we have added tick boxes for ‘yes’ or ‘no / N/A’, and the form now states that
further information must be provided if the ‘no / N/A’ is ticked. This improvement will allow
further reflection as to why any measures have not been implemented whereas previously,
they did not need to provide further reasoning.

The updated pre-admission assessment and admission checklist will be live on our intranet “mycareuk”
from 7 October 2025 and an email from our internal communications platform “icommunicate” will be
circulated with a link to these forms on the same day.

Nurses’ knowledge

You also raised concerns that the nurses who gave evidence during the inquest lacked knowledge of the
timing for completing the bed rails assessments in paragraphs 4, 5 and 6.

“4. A registered general nurse involved in care for Marion Jones, and who
found her after she had fallen, gave evidence that an assessment for bed rails
should have taken place 48-72 hours after admission. The manager of the care
home gave evidence that such an assessment should take place as promptly as
possible, and that 48-72 hours did not meet this requirement. The nurse did
not appear to appreciate the time within which such an assessment should be
conducted.

5. Another registered general nurse involved in the care of Marion Jones
gave evidence that she was not sure in what period of time an assessment for
bed rails should take place.

6. Therefore, nursing staff responsible for the care of Marion Jones did not
know what the appropriate approach was to assessment for bed rails. The
awareness of nursing staff at Riverside with regard to assessment for and / or
the requirement for bed rails was not apparent”

As previously outlined, we have made changes to our pre-admission pro-forma and admission checklist
that will ensure that colleagues consider bed rails assessments before and after admission. In addition
to these changes, we are launching a Bed Rails eLearning module which will improve the knowledge of
colleagues assessing residents in relation to our policies and procedures regarding bed rails assessments.
This eLearning module will be live on our e-learning platform from 13 October 2025.

Also, we have amended our documentation on our “Go Audits” tool. These are audits completed on a
monthly basis by our Deputy Home Managers. They look at the individual assessments that form part
of a resident’s care plan, for example: MUST Assessment, MFRA Assessment, Choking Risk Assessment,
etc. The Audit ensures that all necessary parts of a care plan have been completed, all necessary
information has been included, and the information is up-to-date. We have now added an additional
question that covers the completeness of the Admission Checklist within the required timeframes.
These amendments will go live this month and will allow management to audit compliance with the
implemented changes.

Finally, we have updated our Care & Clinical Meeting Notes form to include that checks should be made
as per completed risk assessments, and that the admission checklist should be fully completed within
the required timeframes.

Previous Incidents

Your final concern was regarding evidence given during the inquest that there have been previous
incidents where bed rails have not been in place. | discussed this concern with the Home Manager and
the Regional Director for Riverside care home. Danielle explained that during the inquest she gave
evidence that previous incidents had occurred where bed rails were not in place. However, she
explained to me that she was referring to incidents where residents had rolled out of bed without bed
rails in place, but a low-rise bed with a crash mat was in place in order to prevent injury. She has
reassured me that she was not referring to any previous incident where a resident with no bed rails had
fallen out of bed with no fall out (crash) mat.

According to Care UK’s falls management and prevention policy high/low beds should be considered as
an alternative to bed rails (6.4). These measures are considered a less restrictive option for residents at
risk of falling out of bed.

We are confident that we have implemented a robust series of improvements to our forms, training and
audits which address the concerns that were raised during the Coroner's inquest and set-out in the PFD.
However, please do not hesitate to contact me should you have any queries.

Yours sincerely,

4

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Wy, X

lonatha low
General Counsel and Company Secretary

Jonathan.calow@careuk.com

07918-747-878