George Ritchie

Regulation 28:  REPORT TO PREVENT FUTURE DEATHS

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

REGULATION 28  REPORT TO PREVENT DEATHS

THIS  REPORT IS  BEING SENT TO:

1 

, Chief Executive Officer, Cardinal Healthcare, Paramount House,

1 Delta  Way,  Egham, SURREY TW20  8RX

1

CORONER

I  am David REID, HM Senior Coroner for the coroner area of Worcestershire

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 07 May 2025 I  commenced an investigation and opened an inquest into the death of
George Lawrence RITCHIE aged 89. The investigation concluded at the end of the inquest
on 21 January 2026. The conclusion of the inquest was that:
Narrative Conclusion - Died from natural causes and the effects of a fractured femur
sustained in a recent accidental fall.

4

CIRCUMSTANCES OF THE  DEATH

On 12.2.25 George Ritchie, who lived with a number of significant medical conditions, was
admitted to Worcestershire Royal Hospital after suffering an unwitnessed fall at The
Meadows Nursing Home, Bromsgrove, where he lived, in the early hours of that  morning.
He was found to have sustained a fractured hip, which was fixed surgically the following
day. In  the weeks following surgery he required further treatment for urinary and chest
infections. He was discharged to Brindley Manor Nursing Home, Droitwich Spa on 25.3.25,
where he continued steadily to decline and died on 29.4.25.

5

CORONER'S CONCERNS

During the course of the investigation my inquiries 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:

Although The Meadows Nursing Home's former Care Home Manager and former Clinical
Lead and Deputy Manager accepted in evidence that Mr. Ritchie was a high risk  of falling,
the falls risk assessments and care plans in place for him  from December 2024 onwards
were wholly inadequate. Not only  were those documents not completed properly, but there
was no system of checks and oversight in place to ensure that  they  were being completed
properly.
One of those who failed to complete the falls risk assessment correctly  was the Clinical Lead
and Deputy Manager. There was no system in place from above her to ensure that she was
doing her job correctly.
From January 2025 Cardinal Healthcare's newly appointed Operations Manager, with a
wealth of experience as a Care Home manager herself, was meant to address the many
concerns about the Meadows Nursing Home raised in recent CQC inspections. There was no

Regulation 28 -  After Inquest
Document Template Updated 30/07/2021

 evidence that she had even attempted to put in place some sort of supervision or oversight
at The Meadows Nursing Home to ensure that important documents like these, which
played a key part in keeping residents safe, were completed properly.
I  am also concerned that there appears to have been no recognition by Cardinal Healthcare
that night-time staffing levels at The Meadows Nursing Home at the material time  were
concerningly low, and required addressing.
The Meadows Nursing Home may now have closed, but Cardinal Healthcare continues to
operate other nursing homes in other parts of the country. I  am concerned that if Cardinal
Healthcare failed to put in place at The Meadows Nursing Home sufficient oversight to
ensure documentation was being completed correctly, and failed to recognize and act upon
low staffing levels, there  will remain a risk that  the lives of residents at their other nursing
homes may be put at risk.

6

ACTION SHOULD BE TAKEN

In  my opinion action should be taken to prevent future deaths and I  believe you (and/or
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 March 18, 2026.  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.
COPIES and  P U B L I C A T I O N

8

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

 (  Mr.  Ritchie's son  )

Care  Q u a l i t y  Commission

  (  f o r m e r  clinical lead  and  d e p u t y  m a n a g e r  of  The  M e a d o w s  Nursing

Home  )

 (  f o r m e r   m a n a g e r  of  The  M e a d o w s  Nursing Home  )

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 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 by the Chief Coroner.

9

Dated:  2 1 / 0 1 / 2 0 2 6

David  REID

Regulation 28 -  After Inquest
Document Template Updated 30/07/2021

 HM Senior Coroner for
Worcestershire

Regulation 28 -  After Inquest
Document Template Updated 30/07/2021

Cardinal HC Ltd 
Paramount House 
1 Delta Way, Egham 
Surrey, TW20 8RX 
Tel: 01932 253 403 

David Reid 
HM Senior Coroner for 
Worcestershire 

Dear Coroner, 
Thank you for your recent correspondence regarding matters at The Meadows. Please find 
below Cardinal Healthcare’s formal response. 

Organisational Governance, Structure and Responsibilities 
Cardinal Healthcare operates within a mature and comprehensive governance framework 
designed to safeguard the safety, wellbeing, and dignity of all individuals in our care. Every staff 
member is employed under a clearly defined job description outlining their duties, delegated 
responsibilities, and accountability structures. All clinical and care staff maintain registration with 
the relevant professional and regulatory bodies to ensure lawful, competent, and ethical practice. 
Our governance systems incorporate: 

  A comprehensive policy framework encompassing clinical care, safeguarding, risk 

management, medicines management, incident reporting, infection control, and quality 
assurance. 

  A structured audit programme, including monthly internal audits and periodic independent 
audits, ensuring adherence to organisational standards and regulatory expectations. 
  Operational protocols and supervision systems that provide consistent oversight of staff 

performance, regulatory compliance, and safe practice. 

  Mandatory training and competency reviews, aligned with the Care Act, CQC 
Fundamental Standards, and applicable professional codes of conduct. 

Since its inception, Cardinal Healthcare has relied on these systems to maintain high-quality care 
and a safe, well-governed environment for all residents. 

Findings Related to The Meadows 
Our internal investigations identified that the management team at The Meadows did not adhere 
to established Cardinal Healthcare policies and procedures. These departures from expected 
standards constituted a significant breach of organisational governance and leadership 
responsibilities. 
As a result: 

  The Home Manager was placed into disciplinary proceedings for failing to uphold policy, 
maintain effective oversight, and ensure compliance with organisational expectations. 
The Manager subsequently resigned during the disciplinary process. 

 
 
 
 
 
 
 
   Following the Manager’s departure, temporary oversight was delegated to the Clinical 

Lead. However, the Clinical Lead did not demonstrate the transparency, accountability, 
or cooperation required in such a role. Their conduct was inconsistent with organisational 
protocols and contributed to operational deterioration within the home. 

  Staffing levels remained above dependency needs for more than a year, and all 

amendments to staffing were made in consultation with the Clinical Lead at the time. 
Notably, no reports were produced or documented by the home regarding recurrent falls 
for the resident later admitted to hospital in February 2025. 

In the interests of transparency and to support the Coroner’s understanding of the wider context, 
Cardinal Healthcare considers it relevant to note that this was the second care home in which 
the Clinical Lead concerned had been associated with serious governance failures involving the 
provision of misleading information to the provider. Whilst we do not seek to speculate on future 
conduct, our experience gives rise to a reasonable concern that similar risks could arise in any 
future appointment if appropriate oversight is not exercised. We sincerely hope that this is not the 
case. In order to assist your office fully and to ensure that any regulatory considerations are 
informed by a complete picture, we have attached a copy of the individual’s previous 
employment reference, which documented concerns of a similar nature and which, regrettably, 
were not appropriately escalated and policies not followed at the point of recruitment by the 
Manager and the Operational Manager. Cardinal Healthcare retains copies of the relevant 
correspondence. 

Additionally, the Operational Manager, who held responsibility for governance oversight at The 
Meadows, did not maintain sufficient supervisory control. This failure contributed materially to the 
decline of the service and caused significant organisational harm. The Operational Manager has 
since left Cardinal Healthcare prior to disciplinary proceedings. 
These events were deeply regrettable and do not reflect Cardinal Healthcare’s values, systems, 
or long-standing commitment to high-quality, safe care. 

Commitment to Quality, Learning, and Improvement 
Cardinal Healthcare has consistently prioritised the provision of a safe, caring, and well-governed 
environment. In response to the issues identified at The Meadows, we have strengthened our 
systems further, including: 

  Enhanced internal audits, ensuring continuous compliance and improvement. 
  Policy updates and targeted staff re-training, informed by incident learning and emerging 

best practice across the sector. 

  Strengthened recruitment and HR protocols, including rigorous reference checks and 

improved verification of prior employment concerns. 

  Revised governance and reporting structures, with increased senior-level quality 

oversight. 

The organisation has also issued a formal notification to the Care Quality Commission (CQC), 
the Local Authority (WCC), and the Integrated Care Board (ICB) outlining concerns regarding 
their oversight of the home, which we believe was neither unbiased nor conducted in a 
supportive manner and appeared instead to reflect a predisposition towards closure. 

 
 
 These measures reflect Cardinal Healthcare’s enduring commitment to learning, accountability, 
and continuous improvement. The lessons from The Meadows have been taken seriously, and 
we have used this experience to reinforce our organisational resilience and strengthen the quality 
of care we provide. 
Cardinal Healthcare remains dedicated to its mission to be a leading healthcare provider within 
the community—delivering compassionate, safe, and dependable care to every resident we 
support. 
Should your office require any further information or clarification, we remain fully at your disposal. 

Yours sincerely, 

PP 

Cardinal Healthcare