Pauline Stirling

Leila Benyounes 
Assistant Coroner for Gateshead and South Tyneside 
Town Hall and Civic Offices 
Westoe Road 
South Shields 
NE33 2RL 

Dear Ms. Benyounes,  

3 December 2025 

We write further to the Regulation 28 Report issued on 9 October 2025, following the Inquest 
touching the death of Mrs. Pauline Stirling. We extend our deepest sympathies to the family 
of Mrs. Stirling, who was a much-loved resident of Covent House Care Home (the “Home”).  

Mrs.  Stirling  sadly  died  on  7  March  2024,  with  the  medical  cause  of  death  being 
Bronchopneumonia,  chronic  osteomyelitis  secondary  to  pressure  sores,  with  contributing 
conditions of Alzheimer’s Disease and Lewy Body Dementia.  During the Inquest, the Court 
heard  evidence  about  the  measures  Malhotra  Care  Homes  Limited  (the  “Company”)  have 
implemented  since  Mrs.  Stirling’s  residency  at  the  Home  circa  two  years  ago.  We 
acknowledge  the  Court’s  concerns  that  further  work  from  that  time  would  be  required, 
particularly in relation to pressure damage prevention, and we welcome the opportunity to 
provide  assurance  that  significant  improvements  have  been  made  and  continue  to  be 
embedded across the Company. 

We have addressed each of your  matters of concern in detail below, and have provided a 
bundle of supporting documentation.  

1.  To date, the documentation for recording positional changes only requires care staff to 
input the position right, left, back, in chair with no reference to positional tilt to avoid 
pressure damage.  

As  referenced  during  the  Inquest,  the  Home  transitioned  to  an  electronic  care  recording 
system, Nourish, in May 2024. We acknowledge that this is a fairly new system, and that prior 
to the Inquest, there was no ability to input a positional tilt in the positional changes screen 
of Nourish. Immediately following the Inquest, we added a 30-degree tilt interaction, named 
a ‘hip tilt’, which is evidenced in our supporting documentation bundle (Exhibit 1).  

Registered Office:  Malhotra House, Malhotra Group  PLC, 50 Grey Street, 
Newcastle upon Tyne, NE1 6AE 
 Tel: 0191 233  0387  Fax:0191 260  2342  Email: reception@malhotragroup.co.uk 
Web:  www.malhotragroup.co.uk  
Malhotra Group  PLC (7918146) & Subsidiary Companies. VAT  Reg. No. 175 4446 89 

  
 
 
 
 
 
 
 
 
 The 30-degree tilt reflects the ’30 Degree Tilt – to support pressure relief’ leaflet, provided by 
the  Tissue  Viability  Service,  a  copy  of  which  is  supplied  in  the  supporting  documentation 
bundle (Exhibit 2). This provides that a 30-degree tilt allows care givers to reduce pressure 
relief for individuals who are unable to self-reposition in bed by reducing direct pressure to 
the  larger  bones  of  the  lower  back,  tail  bone,  buttocks  and  hips.  By now  adding  this  in,  it 
allows greater transparency of the positional changes being made to any resident.  

2.  Whilst evidence was provided about the training requirements for full time members of 
nursing and care staff, to include mandatory full induction and refresher training, I am 
concerned having heard evidence that to adhere to the ratio of 2 RGNs per shift, agency 
nurses  were  regularly  utilised,  and  no  evidence  about  training  requirements  was 
provided. 

The Company has taken steps to reduce its reliance on agency staff. This is demonstrated by 
an  11.95%  decrease  in  expenditure  on  agency  staff  between  February  2024,  when  Mrs. 
Stirling  was  a  resident  in  the  Home,  and  October  2025.  This  reduction  has  been  achieved 
despite the inflation in wages that have occurred throughout this time period, including the 
effect  of  two  national  minimum  wage  reviews.  In  real  terms,  this  would  equate  to  an 
additional 11-15%. Where agency nurses are needing to be engaged, the Company requires 
the agency to provide evidence of mandatory training compliance, ensuring that our agency 
colleagues meet and maintain the professional standards expected from our own employees 
prior to their arrival a the Home, so to allow the home manager to assess the same.   

3.  Despite safeguarding referrals made due to concerns about wound management, and 
the  issue  of  wound  care,  incorrect  classification  of  pressure  damage,  and  absence  of 
expected documentation being raised initially by tissue viability nurses in January 2024, 
there  is  no  evidence  before  the  Court  of  training  having  been  undertaken,  including 
training  offered  by  tissue  viability  nurses.  The  only  training  carried  out  was  online 
webinar training by a former member of staff in March 2024. 

This has been taken on board by the Company, and we can confirm that staff at the Home 
have  been  booked  onto  training  provided  by 
,  Senior  Tissue  Viability 
Specialist  Nurse  for  the  Gateshead  Health  NHS  Foundation  Trust.  This  training  will  cover 
pressure ulcers and wound management and is booked for 16 and 17 December 2025. We 
attach a copy of the confirmation of this booking (Exhibit 3).  Furthermore, we have sourced 
and delivered additional wound management training across the Company from an external 
company  called  ‘Caring  for  Care’.  This  is  ongoing  training,  with  further  training  sessions 
booked for 2026, and has been carried out by staff including Home Managers, Deputy Home 

Registered Office:  Malhotra House, Malhotra Group  PLC, 50 Grey Street, 
Newcastle upon Tyne, NE1 6AE 
 Tel: 0191 233  0387  Fax:0191 260  2342  Email: reception@malhotragroup.co.uk 
Web:  www.malhotragroup.co.uk  
Malhotra Group  PLC (7918146) & Subsidiary Companies. VAT  Reg. No. 175 4446 89 

  
 
 
 
 
 
 Managers, Nurses, Senior Care Assistants and Care Assistants. Online training is also shared 
with the homes across the group, with staff encouraged to attend, including Online Tissue 
Society training and E-learning training for Healthcare.  

Internally,  managers  meetings  have  included  reflective  sessions  from  Nursing  Standards 
News, the management of skin tears has been shared with all home managers and nurses and 
minuted wound-care specific meetings and supervisions have been carried out with all home 
managers.  

The Company is committed to embedding a proactive and preventative approach to wound 
care,  ensuring  that  our  staff  receive  appropriate  and  ongoing  training.  Our  Training  & 
Development  Policy  Statement,  which  echoes  these  sentiments,  is  reviewed  annually  at  a 
minimum.  

4.  There were candid acceptances that documentation was not completed to an accepted 
standard  and  there  were  gaps  in  the  records.  This  is  not  the  first  inquest  where 
acceptances  were  made,  therefore  I  remain  concerned  that  this  is  an  ongoing  issue 
despite evidence that this has been addressed with an auditing system 

We have made significant efforts to improve our ways of proactively preventing the potential 
for  gaps  in documentation.  Since  moving to  a  digital platform and  changing the  system  as 
needed, we are now able to clearly identify when records have not been completed within 
the  agreed-upon  timeframe,  as  Nourish  will  automatically  generates  an  alerts  should  this 
occur. This is evidenced in the supporting documentation bundle. The first screenshot (Exhibit 
4) illustrates an example of a resident’s timeline. This timeline captures the resident’s daily 
needs and any required tasks that must be completed each day, which are tailored to the 
resident’s  individual  requirements  and  preferences.  It  focuses  on  scheduled  care,  such  as 
mealtimes,  personal  care,  clinical  interventions,  positional  changes  and  assessments.  The 
second screenshot (Exhibit 5) highlights the alert function under the ‘warnings’ header in the 
rask bar and on the ‘alarm bell’ in the top right corner. When a time-sensitive interaction is 
due, the system will trigger an alert if it has not been completed within 15 minutes, and again 
at 30 minutes. An ‘amber bell’ is escalated to nursing staff and a high-level ‘red warning’ is 
escalated to the Care Home Manager. This provides an additional safeguard to ensure that 
care  is  delivered  when  schedules,  and  that  residents’  needs  are  met  consistently  and 
promptly.  Please  note  that  the  screenshots  in  the  bundle  are  from  the  training  mode  of 
Nourish,  and  therefore  do  not  represent  the  needs  of  an  actual  resident  due  to  Data 
Protection purposes. Therefore, the number of alerts visible on the right hand side of the first 
screenshot would not be reflective of an operational home.  

Registered Office:  Malhotra House, Malhotra Group  PLC, 50 Grey Street, 
Newcastle upon Tyne, NE1 6AE 
 Tel: 0191 233  0387  Fax:0191 260  2342  Email: reception@malhotragroup.co.uk 
Web:  www.malhotragroup.co.uk  
Malhotra Group  PLC (7918146) & Subsidiary Companies. VAT  Reg. No. 175 4446 89 

  
 
 
 
 
 
 Nourish provides a ‘Wound Management View’, upon which care givers can see everything 
relevant  to  the  wound  in  one  place.  Nourish  proves  a  complete  history  of  care  with 
interactions  recorded  in  the  past  and  scheduled  in  the  future  to  manage  a  wound  or  skin 
concern.  When  a  new  wound  is  recorded,  the  system  will  bring  up  different  assessments, 
tailored to that specific wound type such as pressure damage, skin tears and moisture lesions. 
Within the ‘Initial Assessment’, care givers will be required to describe the wound in detail, 
upload a photograph and define a treatment plan. Wounds and body maps can also be linked 
to the resident’s care plan. A copy of the Nourish training guide on wound management is 
included in the bundle of supporting documentation (Exhibit 6).  

The  implementation  of  Nourish  has  significantly  strengthened  our  oversight  of  wound 
manacomplete gement. Through the Nourish dashboard, the Home Manager can monitor and 
review all wounds within the care home, ensuring that any concerns are addressed promptly. 
At  an  organisational  level,  the  Operations  Team  has  a  satellite  view  across  all  care  homes 
within the Company, with each care home having its own dedicated Operations Manager to 
provide  targeted  oversight  and  guidance.  Additionally,  our  Director  of  Care  is  holding 
fortnightly  meetings  to  discuss  wounds  and  the  management  of  wounds  within  all  care 
homes, ensuring consistent standards, shared learning and continuous improvement in the 
management of wounds.  

We hope that this response, outlining the steps we have taken since the Inquest, and over 
the  past  two  years  since  Mrs.  Stirling’s  residency  within  the  Home,  provides  you  with 
confidence  that  we  have  taken  the  Court’s  concerns  seriously.  We  recognise  that  the 
prevention of future deaths is not achieved through isolated measures but through sustained 
vigilance and continuous improvement. As a Company, we are committed to ensuring that 
the measures taken lead to lasting improvements, not only within Covent House but across 
our wider organisation.    

Yours sincerely 

On behalf of Malhotra Care Homes Ltd  
Encl. Supporting Documentation Bundle  

Registered Office:  Malhotra House, Malhotra Group  PLC, 50 Grey Street, 
Newcastle upon Tyne, NE1 6AE 
 Tel: 0191 233  0387  Fax:0191 260  2342  Email: reception@malhotragroup.co.uk 
Web:  www.malhotragroup.co.uk  
Malhotra Group  PLC (7918146) & Subsidiary Companies. VAT  Reg. No. 175 4446 89