Thompson Elliott

Mr David Place
HM Senior Coroner for the City of Sunderland
Office of HM Coroner for the City of Sunderland
City Hall
Plater Way
Sunderland SRI 3AA

care UK Q

Connaught House
850 The Crescent
Colchester Business Park
Colchester

Essex
C04 9QB

Tel 0300  130 3030
careuk.com

10 December 2025

Dear Mr Place,

Thompson Elliott - Prevention of Future Deaths report

We write further to your Prevention of Future Deaths report (PFD) issued on 15 October 2025
following Mr Elliott's Inquest. 
carry out a thorough investigation before formally responding.

the Chief Executive Officer of Care UK, asked me to

I am a Solicitor having qualified in 1996.  I 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 a Prevention of Future Deaths report very seriously. The investigation has involved
, the Regional Director

the Home Manager of Grangewood care home; 

who manages 
Head of Regulatory Governance and 
manages 

.

, the Head of Nursing, Care and Dementia; 

,

 the Director of Care, Quality and Governance who

First, we respectfully remind the Court of the information provided at the inquest in terms of the steps
undertaken following the incident and prior  to  the  inquest. As set out  by the  Home  Manager in her
statement for the inquest and confirmed by her in evidence, following investigation of the case by the
care home, extensive discussions were undertaken with all care home staff including reference to the
Medication Administration Record and wider records, to ensure all clearly understood what went wrong
in Mr Elliott's case and the steps that need to be taken to prevent repetition. These steps focused upon
(a) Checks to  be made when a resident returns to the  care home following admission to  hospital; (b)
Documentation and communication requirements; and (c) Medication knowledge and confidence to
challenge.  Each of  these  are  elaborated  upon  below,  including  further  information  (and  enclosed
relevant documentation to illustrate) of further steps taken since the inquest.

Steps taken since the incident/inquest

(i) 

Checks when a resident returns to the care home from hospital

The initial failing in this case was around not taking all reasonable steps to establish the position when
Mr Elliott returned from the hospital with new medication but no discharge documentation.

Discussion and further refresher training with all relevant staff has emphasized the need to ensure home
management is informed immediately of any concerns regarding residents returning from hospital and
that checks are undertaken with the hospital. The training has reinforced that if the hospital cannot be
reached for  an answer, colleagues should check with  the GP and failing that  contact the  111 service.

Care UK Community Partnerships Limited  Registered in England. Registration Number  02644862
Registered office: Connaught House  850 The Crescent. Colchester Business Parte, Colchester. Essex CO4 9QB

 The emphasis is upon obtaining same day advice to resolve any concern/query so as to  ensure correct
and  timely  administration  of  the  required  medication.  These  enquiries  must  continue  before
administration of medication, where there is any doubt or lack of clarity.

To remind staff, a visual flow chart has been introduced at the care home to provide clear, step-by-step
guidance  for  staff  involved  in  supporting  residents  returning  from  hospital  where  there  is  no
accompanying discharge letter to  support changes in  medication. A copy  of this flow  chart, which has
been shared and discussed with staff to  embed awareness of it, accompanies this letter (enclosure 1).
This  flowchart  is  laminated  and  attached to  the  medication keys  as  an  immediate  prompt  to  staff.
Additionally,  there  are  copies  of  this  flow  chart  in  poster  format  on  the  wall  of  the  care  home's
treatment room  and  there  is  a  further  copy  contained within  a  dedicated discharge file  held  in  the
Deputy Manager's office. This dedicated file  has been brought in following this  case and contains the
flow  chart prompt and copies of Care UK's relevant up-to-date policies to which I refer below.

The care home leadership has reinforced Care UK's 'Admissions and Discharge Policy' (enclosure 2) and
the  'How  to  Guide  -  Supporting  a  Resident  Returning  from  Hospital'  (enclosure 3)  as  well  as  the
'Medications Management Policy' (enclosure 4). These documents provide clear guidance to staff as to
whatto do in circumstances where a resident arrives and/or returns to the care home from hospital and
there is insufficient/absent information regarding their  discharge and attendant medications. All staff
have completed a mandatory "read and sign" process to  confirm that  they have read and understood
these  documents,  all  of  which  have  been  discussed  with  staff  as  part  of  further  refresher  training
sessions undertaken.

The Home Manager and/or Deputy will ensure that  any imminent or new  discharges to the care home
are discussed at the daily 10@10 meetings and weekly clinical review meetings to ensure staff are aware
of  the  discharges,  the  relevant  information  is  obtained  and  any  matters  requiring  follow-up  are
actioned. In addition, it  is also important to  note  that  there  is always a member of  the  management
team  available (seven days a week) and so at any time the  discharge process is taking place, there are
senior staff available to help deal with/advise on any issues arising with the discharge.

Since the incident, the Home Manager has met  with the care home's allocated Trusted Assessor at the
local  hospital  Trust  (the  individual  leading  on  Discharges/the  Discharge  Lounge)  to  review  Care  UK
processes, and to  explain why  staff  will  be asking the  questions they  will be asking the hospital team.
The Trusted Assessor has provided very positive feedback in relation to these and is in agreement with
their  use  to  facilitate the  care  home  staff  completing the  necessary  documentation and  accepting a
discharge.

As set  out  later  b e l o w ,  these processes have  a l r e a d y  been  effective in  practice.

(ii) 

Documentation and communication:

Another factor  identified in  this  case was  poor  recording of  the  issue  (the  medication query), action
taken and handover/communication of the issue and action needed.

Refresher training has since focused upon  the  need to  properly document the  issue (in  this  case the
absence of discharge notice/instructions and presence of new medication in replacement of a previous
medication) in the  records and  at  handover (10@ 10,  Clinical Review  meetings) to  ensure all  relevant
staff at the  care home are clear about what the issue is, the calls that have been made for  clarification,
the results of those, what further steps need to be taken (and their urgency) and, crucially, what should
be  done/any advice received with  regard to  the  medication pending clarification. The care  home has
also sought to emphasize the need to ensure Team Leaders and home management are made aware of
the issue to  ensure answers are provided with  sufficient urgency and that  there is clarity around who
will take the task forward.

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 Training and discussion around the above mentioned policies has emphasized the need to document in
the resident's own daily care notes as well as the communications/handover book all interactions/calls
made  with  other  providers/services to  ensure all those interacting with the resident are  aware of  any
issue arising, the need for that to be resolved and what steps have been taken to date to do so.

There is now  a monthly review of hospital discharges checking compliance with the relevant processes
outlined above; medication is promptly updated and any required follow-up actions completed.

(iii)  Medication Knowledge and confidence to  challenge:

Whilst  Grangewood is  a  residential  care  home,  not  a  nursing  home,  it  has,  as the  Home  Manager
explained in her statement and at the inquest, worked hard to improve medication knowledge.

The care home has run extra medication training sessions to raise knowledge of and test understanding
of drugs in use at the care home including whythey are prescribed, the effects/side effects, brand names
and  generic  names.  The  refresher  training also  included how  the  online  British  National  Formulary
should be used. To begin with this additional training focused only on the  pain relief medication in Mr
Elliott's case but, due to its success, has since focused on other drugs commonly in use at the care home.

Staff  have  worked through a Medication Reflection and Training Workbook to  further assist learning
and best practice in line with the Medications Management policy. All staff have completed a mandatory
"read  and  sign"  process  to  confirm that  they  have  read  and  understood the  policy. The  care  home
management team  has  also  reset  the  learning cycle to  ensure  all  staff  recomplete their  medication
training and the  care home has re-run EMAR training (exploring the  use of the  Electronic Medication
Administration Record including further information and  resources  which  can be  used to  understand
medications and potential issues with the same).

The aim has been to  encourage staff to think more deeply about the medication, prescribed by others,
that they are administering and to have greater confidence to raise questions if something may not look
right, and to ensure compliance with Care UK's expectations in relation to medicine management.

Continued partnership with discharging hospitals:

The  care  home  has  continued to  work  closely  with  the  Trusted Assessor team  at  the  hospital  which
discharged Mr Elliott to try to  streamline communication/interaction in relation to discharges. The aim
is  to  ensure  all  documents  are  securely  and  promptly shared  including via  NHS email  if  possible to
support timely and safe transitions of care from hospital to the care home.  This work is ongoing but the
care  home  and  its  hospital partners share  a commitment to  best  practice to  achieve these  aims.  As
noted above, the Home Manager has held meetings with the local hospital's Trusted Assessorto discuss
the care home's discharge policies to ensure agreement and buy in to the process.

The  care  home  management  team  has  also  re-emphasized  (to  Care  UK colleagues  and  the  hospital
Trusted Assessor team)  the  importance of  its  hospital travel  passport. This  document goes  with  the
resident whenever they  attend hospital and  is requested to  be  returned with  them  when  they  come
back. The first page provides a profile of the resident and his/her needs, and full details of their next of
kin along with  their  contact details. The second page is any DNAR/ECHP in place for  that resident and
the  final  page  is  a  copy  of  the  EMAR  for  that  resident  to  ensure  the  hospital  has  clear  information
regarding the relevant medications taken by the resident. The care home has updated the document to
ensure that  it  now  contains, in  addition to the  main care home number, on-call numbers for  all of the
care home's team leaders to provide hospital staff with a number of potential points of contact. Again,
in  meetings with  the  Trusted Assessor from  the  local hospital, this  has been  discussed  and  emphasis
placed upon the need for hospital staff to ensure its return with the resident on discharge.

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 Recent evidence of effectiveness:

As confirmed at the  inquest, the  care home  had  a resident return from  a hospital in  September 2025
without  direct  handover  and  without  a  discharge  letter.  The  Team  Leader  on  duty  immediately
escalated this to management and undertook relevant enquiries of the hospital, challenging the fact of
the  discharge without relevant information. The Team  Leader  ensured same day  delivery to  the  care
home  of the  required documentation and follow up contact ensured all information for  safe return to
the care home was obtained.

Since then, in October 2025, the care home was contacted by the hospital discharge lounge regarding a
resident about to return that day to the care home. This was the first time there had been any indication
that a discharge was taking place. Staff followed the correct processes with prompt calls to the hospital
team in order to ensure they had the information required to accept the discharge and identified, by so
doing, that  the  resident did  not  have his hospital passport with  him  at  point  of  discharge, and hence
further enquiries were made to the hospital to seek its recovery.

Conclusion

Grangewood care home and Care UK reiterates its regret with regard to the  errors in Mr  Elliott's case.
Care UK and the home have worked hard to  ensure training and reflection by all staff and to ensure all
appropriate policies and processes are known and understood by staff, so as to do all they can to prevent
repetition.

Yours sincerely,

General Counsel and Company Secretary

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