Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0049, written 30 Jan 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Jan 2026 |
|---|---|
| Reference | 2026-0049 |
| Deceased | Pamela George |
| Coroner | Deborah Archer |
| Coroner area | Devon, Plymouth and Torbay |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. – Manager Cann House Managing Director of Premiere Health Ltd 1 CORONER I am Deborah Archer, Area Coroner for the County of Devon, Plymouth and Torbay. 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 6th July 2023 I commenced an investigation into the death of Pamela George aged 70. The investigation concluded at the end of a 1-day inquest on 22nd January 2026 the conclusion of the inquest was a narrative one namely: Narrative The Deceased died at Derriford hospital from acute renal failure and sepsis caused by an infection underneath the breast in circumstances where there were missed opportunities by her care home to treat her and escalate medical concerns. 4 CIRCUMSTANCES OF THE DEATH Pamela George was 70 years of age when she died at Derriford hospital on 30th June 2023. She was a vulnerable lady who lacked capacity and was diagnosed with a learning disability and had suffered from significant ill health in the lead up to her death in that she had been an in-patient at Derriford Hospital from 1st May – 24th May 2023 and then been discharged to Cann House where she was registered as a temporary resident because of concerns with her previous supported living accommodation. She had been in hospital because of bilateral leg swelling and general deterioration and of note she had acute kidney injury on chronic kidney injury on admission which was treated successfully. She also had a large haematoma on the right iliac fossa which was managed conservatively and she also had a breast wound that was described as cracked and open. On discharge to Cann House the discharge summary from Hospital made it clear that because of her acute kidney injury she should have post discharge monitoring blood tests every 5-7 days. This was not done and it was accepted by the home that this meant no one was monitoring Pam ‘s bloods from the day she left hospital until she was readmitted to Hospital by I was told by the home during evidence that Ms George did not have capacity, but they were unable to provide me with copies of mental capacity assessment during the inquest and accepted that her lack of capacity was not noted on the care plan. The on 29th June 2023 1 Manger could not adequately explain what systems had been put in place to rectify this situation. I was further concerned that although the home’s note of 27th June 2023 suggests that Miss Geroge’s fall had been brought to mention it. The note from the home describing the fall was not detailed enough in terms of observations or descriptions of pain and justification for not seeking further medical escalation could not be provided. attention his note did not saw Miss George on 27/06/23. No concerns about infection to her breast were noted and nothing was reported about a fall. This was despite the fact that the home had described the breasts as “Red raw “on 27th June 2023. saw Miss George at the home’s request on 29th June 2023 where sepsis was suspected. She was urgently admitted to Derriford Hospital where she died shortly afterwards from 1a Acute Kidney injury and sepsis. . 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. – 1. Cann House missed an opportunity to carry out regular blood tests on Miss George between 23rd May and 29th June. These blood tests may have identified the need to continue to treat acute kidney injury which if left untreated may have affected her resilience to infection. The system for ensuring that discharge summaries are actioned was not available for me to see and I was not clear if any policy on this issue existed. 2. The infection which caused her sepsis was a bacterial infection which told me could only have been successfully treated with antibiotics. I am not satisfied that the breast infection was adequately managed at Cann House it being noted that there was no record of how the breast infection was progressing between 25th May and 27th June 2023 . 3. It is likely that Miss George’s needs were too great for the care home and that the withdrawal of 1 to 1 supervision had an effect on the home’s ability to care for her. I do think it likely that she was unkempt because of the inability of staff to meet her needs as well as the sepsis This does not however remove the need for close monitoring of medical conditions and appropriate escalation policies to be followed and to happen. The home has been unable to provide me with evidence that they appropriately escalated concerns to Adult Social Care which may have resulted in additional care or Miss George being removed to another provider. 4. The documentation surrounding the fall, the symptoms seen and measures taken to seek medical input were not clear. 5. There was little or no evidence that capacity had been appropriately documented with care plans remaining silent on the issue and records not analysing carefully what steps had been taken to help Miss George make decisions. 6. There was little or no evidence of policies in place generally at the home and in particular on medication, escalation and reporting of concerns . 6 ACTION SHOULD BE TAKEN 2 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 4pm on 30th March 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested persons: City Council , Livewell South West and the Care Quality Commission who may find it useful or of interest. I have also sent it to Plymouth I am also under a duty to send the Chief Coroner a copy of your response. 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 [DATE] 30th January 2026 [SIGNED BY CORONER] 3
1 response 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.
Premiere Health Ltd Providers of Cann House Care Home 25th March 2026 HM Coroner Deborah Archer Area Coroner for the County of Devon, Plymouth and Torbay Dear HM Coroner, Re: Regulation 28 Report to Prevent Future Deaths Inquest touching the death of Pamela George (Deceased) Premiere Health Ltd acknowledges receipt of the Regulation 28 Report issued following the inquest into the death of Pamela George, concluded on 22 January 2026. Firstly, we wish to express our sincere condolences to Ms George’s family following their loss. Premiere Health Ltd and Cann House Care Home have carefully considered the matters identified in your report. While the organisation notes the narrative conclusion reached by the Court, we take the concerns raised seriously and have undertaken a comprehensive review of relevant policies, governance arrangements and operational practices at Cann House Care Home. Set out below is the organisation’s response to each matter of concern. 1. Systems for Actioning Hospital Discharge Summaries and Post-Discharge Blood Tests The Coroner raised concerns regarding the absence of regular blood testing following Ms George’s discharge and the lack of a clear system for ensuring discharge summaries were properly actioned. Following the inquest, the following actions have been implemented: • All staff responsible for admissions have received one-to-one supervision regarding Ms George’s case, ensuring learning is embedded. • Information has been disseminated to all junior staff for awareness training, emphasising the importance of correctly processing admission and discharge documentation. • All hospital discharge summaries are now scanned directly into residents’ care plans upon receipt. • The organisation has enforced its formal Hospital Discharge and Clinical Follow-Up Procedure, which includes: Cann House Care Home Tamerton Foliot Plymouth PL5 4LE Telephone – 01752 771742 o Senior staff review of all discharge documentation within 24 hours. o Use of a Clinical Action Log to record and allocate required actions (e.g., blood tests, follow-ups). o Mandatory confirmation with GP surgeries within 48 hours regarding follow-up requirements. o Management oversight and audit of all discharged-related actions. These measures ensure transparency, accountability, and documented completion of all post-discharge clinical tasks. 2. Monitoring and Management of Infection The Coroner noted insufficient documentation regarding the progression of the resident’s breast infection between 25 May and 27 June 2023. The service has taken the following steps: • Staff have received feedback on the importance of record keeping, particularly where care is refused. • All staff will undertake refresher training on record keeping, including expectations for documenting infection progression. • The Care Manager now conducts daily checks on notes for residents who may be declining personal care or presenting clinical concerns. o In the Care Manager’s absence, this is undertaken by the Team Leader. • Registered Nurses are required to take action on concerns escalated to them and update care plans accordingly. • Wound and Infection Monitoring Chart including documenting photographs is being used effectively to ensure clear, regular and structured documentation. • A consolidated clinical escalation protocol is being implemented, requiring early medical review where symptoms do not improve. • Staff training in infection recognition, wound documentation, sepsis awareness and escalation has been reinforced. 3. Escalation of Increasing Care Needs to Adult Social Care The Coroner identified concerns regarding whether Ms George’s needs exceeded those the home could safely meet, and whether appropriate escalation to Adult Social Care occurred. Actions taken include: • Cann House Care Home has reviewed its acceptance criteria and will no longer accept residents requiring 1:1 support, recognising the significance of the challenges faced in Ms George’s case and wider systemic issues around funding. Cann House Care Home Tamerton Foliot Plymouth PL5 4LE Telephone – 01752 771742 • All staff have been reminded of the importance of documenting and communicating concerns to Social Workers and Adult Social Care, both at admission and throughout residency. • A requirement is in place for multidisciplinary reviews where needs increase significantly. • A documented escalation procedure now mandates notification to the placing authority where needs may exceed home capability. • All escalation discussions and communications with commissioning bodies are now formally recorded. 4. Documentation of Falls and Escalation for Medical Review The Coroner noted concerns regarding the clarity of documentation surrounding Ms George’s fall and post-incident clinical observations. In response: • All staff have been reminded of the established incident procedure. • A new system has been implemented whereby a manager reviews all incident forms immediately following any incident to ensure detail, completeness and clinical appropriateness. • A strengthened Falls Management and Post-Incident Observation Procedures in place, including: o Comprehensive documentation of the fall circumstances. o Required physical observations and pain assessments. o Neurological observations where clinically indicated. o Clear documentation of clinical reasoning regarding escalation to medical professionals. • Mandatory post-fall observation charts are now used for unwitnessed or potentially injurious falls. • All care staff have received refresher training in incident reporting and falls management. 5. Documentation of Mental Capacity The Coroner identified that capacity assessments were not clearly documented. Actions implemented: • All trained staff are completing further mental capacity and MCA training, delivered in-house or via Plymouth City Council. • A formal Mental Capacity Assessment Procedure is now in place requiring: Cann House Care Home Tamerton Foliot Plymouth PL5 4LE Telephone – 01752 771742 o Clear documentation where there is reason to believe a resident lacks capacity regarding a specific decision. o Recording of assessment outcomes in the care plan. o Documentation of best-interest processes where required. 6. Policies and Governance Arrangements The Coroner observed concern regarding the availability and sufficiency of policies, particularly in areas such as medication, escalation and reporting concerns. Actions taken: • A full review and consolidation of all operational policies has been completed. • Updated policies now in place cover: o medication management o o infection control incident reporting o clinical escalation o safeguarding o reporting concerns o hospital discharge management • Policies are now centrally stored within a digital governance system, accessible to all staff. • Regular audits are undertaken to ensure compliance. Governance Oversight and Monitoring To ensure sustained improvement, Premier Health Ltd has strengthened governance oversight through: • Routine clinical audits • Management supervision and competency checks • Monitoring of incident trends • Senior management oversight visits These measures support continuous quality improvement and ensure the actions implemented remain effective and embedded. Conclusion Cann House Care Home Tamerton Foliot Plymouth PL5 4LE Telephone – 01752 771742 Premiere Health Ltd acknowledges the matters raised within the Regulation 28 report and has undertaken a detailed review of the systems and processes in place at Cann House Care Home. The actions outlined above are intended to strengthen clinical oversight, documentation, escalation and governance across the home. We trust that this response assists the Court. Should the Coroner require any further information regarding the actions described above, Premier Health Ltd would be pleased to provide clarification. Yours sincerely Registered Manager Cann House Care Home Tamerton Foliot Plymouth PL5 4LE Telephone – 01752 771742
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