Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0557, written 3 Nov 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Nov 2025 |
|---|---|
| Reference | 2025-0557 |
| Deceased | Brian Lloyd |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. High Meadows Care Home 1 CORONER I am Mr Andrew Walker, HM 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 22 July 2025 I commenced an investigation into the death of, Brian Lloyd, aged 78. The investigation concluded at the end of the inquest on 21 October 2025. The conclusion of the inquest was Consequences of infection following injury during catheter insertion at a care home. The medical cause of death was 1a Septicemia, 1b Urinary Tract Infection, 1c Insertion of urethral catheter. 4 CIRCUMSTANCES OF THE DEATH On the 18th July 2025 Mr Brian James Lloyd died in hospital from an infection following injury caused by the insertion of a urethral catheter. Mr Lloyd awoke as usual on the 12th July 2025 at his care home and all was well until his catheter became blocked. This was between 9.30 and 10.42. A nurse attempted to flush the catheter which was not successful and the catheter was removed. There followed 2 attempts to insert a new catheter . Each of these attempts was not successful and as Mr Lloyd was distressed he was given paracetamol to ease his discomfort. A third attempt was made at 15.40 which was also unsuccessful. A call was then made to the London Ambulance Service at 16;26 and this was transferred to the London Central Urgent Care Center for a clinician to call the care home. There were 3 attempts to call the care home with a connection being successful on the 4th attempt and an ambulance was arranged to take Mr Lloyd to hospital at 17;27. When at hospital the doctors found some difficulty in inserting a catheter until 1 using a more specialised piece of equipment usually only available at a hospital. Despite treatment Mr Lloyd was not able to recover from the infection that arose from the insertion of the catheter and it is likely that the blood seen on the 3rd attempt at inserting the catheter at the care home was the point at which the infection was able to spread. 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. – Where there are two attempts at inserting a replacement catheter, either the same catheter, or a second catheter and both these are unsuccessful the patient will need to be taken to hospital and arrangements for this should be made as without delay. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 Monday 29th December 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: 1. London Ambulance Service 2. The family. 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. 2 9 DATE: 3rd November 2025 3
2 responses 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.
Escalation Protocol for Team Leads Version: 1.0 Date Implemented: 23/10/2025 Next Review: 23/10/2026 Responsible Person: Home Manager 1. Purpose This protocol outlines how Team Leads must recognise, respond to, and escalate any clinical or safety concern promptly and effectively. Its purpose is to safeguard residents, ensure swift clinical response, and promote a culture of professional accountability and continuous learning. This protocol follows current best practice and guidance from: • NMC (2018): The Code. • RCN (2019): Accountability and Delegation. • RCN (2021): First Aid and Emergency Response Guidance. • NICE (2018): NG103: Safe Staffing for Nursing in Care Homes. • NICE (2020): NG159: Recognising and Responding to Deterioration. • CQC (2023): Regulation 12 & 18. • CQC (2022): Key Lines of Enquiry: Safe, Effective, Well-led. 2. Scope This protocol applies to all Team Leads on duty across all units of the home. It supports collaborative practice between Registered Nurses (RNs), Home Management and On-call Clinical Leadership. All Team Leads are trained to: • Recognise abnormal or deteriorating clinical signs. • Record and interpret vital signs and blood glucose readings accurately. • Use appropriate escalation procedures. • Deliver First Aid and CPR in emergencies until the nurse or paramedics arrive. 3. Principles of Escalation Created by: Mariana Costa (Home Manager) Date: 23/10/2025 Next Review Date: 23/10/2026 • Act first to ensure safety — protect the resident and alert help immediately. • If in doubt, escalate. Never wait or assume another person will act. • Escalate concerns via cordless phone or emergency call bell. • Stay with the resident until support arrives. • Document all actions clearly and promptly in care notes and logs. “If you see something, say something — if you’re unsure, escalate.” 4. Emergency Procedure 1. Activate the emergency call by pressing the resident’s call bell (this alerts staff throughout the Home). 2. Call the RN immediately using the cordless phone (each nurse and Team Lead carries one). 3. If there is no response, repeat the emergency call and alert staff in nearby units. 4. Stay with the resident and begin First Aid or CPR if required and within your training competency. 5. If the resident is unresponsive, not breathing, or pulseless, call 999 immediately, start CPR, and continue until help arrives. 6. The RN or on-call Manager must be informed as soon as possible. 7. After the emergency, ensure full documentation of events, times, and actions taken. 5. Clinical Indicators for Escalation 5.1 Vital Signs Vital Sign Normal Range When to Escalate to RN Temperature Pulse 36.0–37.5°C 60–100 bpm Blood Pressure 100–140 / 60–90 mmHg ≥37.8°C or ≤36°C <50 or >110 bpm, irregular rhythm Systolic <100 or >180; Diastolic <60 or >100 Respiratory Rate 12–20 breaths/min <12 or >22 Oxygen Saturation (SpO₂) ≥94% (or resident baseline) Consciousness Alert, responsive <94% or 3% below baseline Drowsy, confused, unresponsive ➡ Immediate Action: Take a full set of observations, remain with the resident, and contact the RN at once. Created by: Mariana Costa (Home Manager) Date: 23/10/2025 Next Review Date: 23/10/2026 5.2 Signs of Infection Escalate if any of the following are present: fever, confusion, reduced appetite, rapid breathing, or wound redness. 5.3 Urinary Catheter and Retention Follow immediately High Meadows’ Catheterisation Emergency & Escalation Protocol. 5.4 Diabetes (Blood Glucose Monitoring) Hypo <4 mmol/L: treat & inform RN. Hyper >15 mmol/L: inform RN. ➡ Never administer insulin without RN delegation. 5.5 Wound and Skin Integrity Report redness, swelling, or new breakdown. ➡ RN to review and document. 5.6 Behavioural and Neurological Changes Escalate if new confusion, drowsiness, slurred speech, or collapse. 6. Communication and Documentation Use SBAR communication and document all observations, actions, and handovers: S – Situation: What’s happening B – Background: Resident info/history A – Assessment: Observations/vitals R – Recommendation: What you need 7. Escalation Hierarchy Created by: Mariana Costa (Home Manager) Date: 23/10/2025 Next Review Date: 23/10/2026 Level Contact Registered Nurse (RN) Availability On site 24/7 Clinical Lead On site and On call 24/7 Home Manager / Deputy Manager On site and On call 24/7 Emergency Services (999) Immediate for life-threatening emergencies GP / NHS 111 As advised by RN or management 1⃣ 2⃣ 3⃣ 4⃣ 5⃣ 8. Post-escalation Process Provide detailed handover, complete incident reports, and ensure RN and management review. 9. Training and Competency All Team Leads are trained in vital signs monitoring, diabetes care, insulin administration, first aid, CPR, SBAR communication, and sepsis recognition. 10. Governance and learning Culture Escalations are reviewed on a daily basis; staff praised for early escalation. Trends inform training and improvement. Created by: Mariana Costa (Home Manager) Date: 23/10/2025 Next Review Date: 23/10/2026
North London Coroner’s Service
Barnet Coroner’s Court
29 Wood Street
London
EN5 4BE
4 December 2025
Dear Sir/Madam
The Inquest Touching the Death of Brian Lloyd
Regulation 28 Report – Action to Prevent Future Deaths – Vivo Medical Care
Limited T/A High Meadows Care Home dated 3 November 2025 (the “Report”)
We refer to the above and write to provide our response to the Regulation 28 Report
to Prevent Future Deaths, received on 4 November 2025.
The Report confirms that the due date for our response is 56 days from the Report,
namely by 29 December 2025.
This response is made under paragraph 7(2) of Schedule 5 of the Coroners and Justice
Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
We understand the response must contain detail of action taken or proposed to be
taken, setting out a timetable for action. Otherwise, we must explain why no action is
proposed.
The Coroner’s Concerns as stated in the Report are: -
“Where there are two attempts at inserting a replacement catheter, either the
same catheter, or a second catheter and both of these are unsuccessful the
patient will need to be taken to hospital and arrangements for this should be
made without delay.”
We provide a list of actions taken and the relevant dates for each as follows: -
T: 02088 681618 W: www.highmeadowcare.co.uk
High Meadows Care Home, High Meadows Close, Pinner, Middlesex. HA5 2HD
Date of Action
05.09.2025
Action Taken
The provision of staff training
An initial group supervision was completed with
all staff on shift at that time. The session
reflected on the incident which took place on 12
July 2025, emphasised the importance of
accurate and comprehensive documentation,
and included a practical demonstration of the
expected standards using “Resident Test”
example notes in Fusion.
To ensure consistency across the whole team,
the supervision notes and example records were
then cascaded to the following shifts on 06/09,
07/09 and 08/09 so that every member of staff
had access to the information and guidance.
Each staff member was provided with a copy of
the example notes as a reference tool.
Staff acknowledged the importance of
comprehensive record keeping, expressed
increased confidence in documenting to the
expected standard, and committed to
strengthening practice moving forward.
A copy of the group supervision record is
attached for your review.
Creation and implementation of a
Catheterisation Emergency & Escalation full
clinical protocol (See enclosed)
23.10.25
Distribution of a Quick Reference Poster to all
nursing stations for immediate guidance in
urgent situations (See enclosed)
23.10.25
A review and reinforcement of training and
competency requirements for all nursing staff
23.10.25
A review of clinical documentation and
escalation procedures to ensure clarity and
accountability.
23.10.25
Creation and implementation of an Escalation
protocol (See enclosed)
23.10.25
Distribution of a Quick Reference Flowchart for
team leads (See enclosed)
23.10.25
We provided a face to face refresher training
session for all nurses and team leads in
catheterization
12.11.25
T: 02088 681618 W: www.highmeadowcare.co.uk
High Meadows Care Home, High Meadows Close, Pinner, Middlesex. HA5 2HD
Post incident action
High Meadows Care has taken several steps immediately following the
incident which are as set out in the above table and detailed on the enclosed
supporting documentation.
In summary in future the home will ensure that protocol is followed and there
will be a maximum of 2 attempts at inserting a replacement catheter. The
attempts will immediately cease in the event of resistance, pain or bleeding
and 999 will be called immediately after 2 failed attempts or sooner if sepsis is
suspected.
Further, in all future emergencies, once the home contacts 999, a 999 call
reference number will be recorded, and a designated staff member with an
allocated phone will remain available to respond promptly to any return calls
from emergency services.
Additionally, we feel it is important to clarify why the calls from emergency
services were missed during the incident. At the time of the incident, the
home’s telephone system was configured so that calls to the care home’s
main line were directed only to the reception phone unless the caller selected
option 3 (‘for Nurses’). If no one was present at the reception desk—such as
on a Sunday afternoon, the call would not be answered immediately, which is
what occurred in this case.
Following the incident, we instructed our telephone provider (BT) to update
our system. It has now been reconfigured so that regardless of the option
selected, if the reception phone is not answered within 10 seconds, the call
automatically diverts to all phones in the building. This ensures that calls
cannot be missed and allows staff to respond promptly.
As an additional measure, we have ensured that portable phones are
available in each unit, supported by several signal amplifiers installed
throughout the home. This guarantees strong, reliable signal coverage across
the building, allowing staff to receive diverted calls wherever they are.
T: 02088 681618 W: www.highmeadowcare.co.uk
High Meadows Care Home, High Meadows Close, Pinner, Middlesex. HA5 2HD
The staff team have been shocked and saddened by the events that led to the
death of our resident, Brian Lloyd and have embraced the changes, training and
clarification of policies that have been made to mitigate the risk of this happening
again in the future.
Mindful of the changes that we have implemented above, and which will be
continuously monitored and reviewed going forward, we believe that all our
residents are appropriately cared for and the environment that they live in is
safe.
We hope we have addressed and allayed the concerns of the Coroner in our
response above.
Yours sincerely,
Registered Manager
High Meadows Care Home
T: 02088 681618 W: www.highmeadowcare.co.uk
High Meadows Care Home, High Meadows Close, Pinner, Middlesex. HA5 2HD
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