Heather Parkhill

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 

 
 
 
 
 
 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 

 
 
 
 •  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 

 
 
 
 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 

 
 
 
 
 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

Swyddfa’r Prif Weithredwr a’r Cadeirydd 
Chair and Chief Executive’s Office 

27 March 2026 

FAO John Gittins 

Senior Coroner North Wales 

Dear Mr Gittins 

Prevent Future Death Report relating to Heather Louise Parkhill. 

I am writing in response to the Regulation 28 report to prevent future deaths, that you issued on 2 
February 2026 and wish to share again my sincere condolences with Mrs Parkhill’s family.  

“For  many  years,  myself  and  other  coroners  have  raised  concerns  regarding  so  called  “ambulance 
delays” and I recognise that the challenges faced by WAST around the availability of resources are the 
result of multifactorial issues, however problems regarding the unavailability of resources persist. I have 
a mandatory statutory responsibility to raise concerns where they exist and it is clear that lives continue 
to be lost as a result of this problem.  
Despite  all  of  the  multi-agency  efforts  to  improve  the  availability  of  resources  and  hence  response 
times, nothing appears to change I therefore remain concerned that lives continue to be at risk.”  

Mae’r Ymddiriedolaeth yn croesawu gohebiaeth yn y Gymraeg 
neu’r Saesneg, ac na fydd gohebu yn Gymraeg yn arwain at oedi 

The Trust welcomes correspondence in Welsh or English, and 
that corresponding in Welsh will not lead to a delay 

www.ambulance.wales.nhs.uk 

Pencadlys Rhanbarthol 
Ambiwlans  

Regional Ambulance 
Headquarters  

Beacon House 
William Brown Close  
Llantarnam, Cwmbran 
NP44 3AB 

Ffôn/Tel  
01633 626262 

 
 
 
 
 
 
 
 
 
 
 WAST response to your concerns 

The  concern  you  express  about  the  continued  impact  and  harm  resulting  from  extensive 
community waits for ambulances is shared by myself, the Executive team and our Trust Board 
at WAST. Over the years, the Trust has shared with you all the measures that have been taken 
in an attempt to manage and address the changes in the pressures both within the Trust and 
across the wider NHS Wales landscape. These actions include: 

• 

Increasing our remote clinical support to ensure we are prioritising our available resources 
effectively based on the presenting needs of patients and also to improve safety netting 
when we are under significant pressures 

•  Minimise the number of patients being transported to already busy hospitals by enhancing 

• 

staff knowledge, skills and competencies and the alternatives available to them  
Increase resources available for use, completing roster changes to increase resource 
availability and improving levels of attendance levels 

•  Offering more treatment at home, or away from the hospital environment in partnership 

with Health Board colleagues 

You  correctly  identify  that  current  challenges  are  multi-factorial  in  cause  and  the  Trust 
continues to work tirelessly with system partners to achieve the changes that our population 
deserves.  

Managing 999 ambulance demand  

In July 2025, a new emergency ambulance performance framework was introduced in Wales, 
supporting a move away from time-based targets towards a more clinically driven, outcome-
focused approach, with an emphasis on responding quickly to people with time-sensitive 
conditions.  

Two new categories of call were initially introduced in July – a new purple category for people 
suffering a suspected cardiac and respiratory arrest and the red category for people at high 
risk of cardiac and respiratory arrest, including where this is a result of injury or illness.  

As part of the framework, all 999 calls to WAST, which are not classified as either purple or 
red,  go  through  rapid  clinical  screening  to  ensure  everyone  receives  a  more  tailored 
approach. This means the ambulance service takes account of their symptoms and where 
the incident occurred to determine what sort of response they receive. Every person receives 
a tailored response but not everyone will need an ambulance – they may receive a different 
clinical response, which is appropriate to their needs. An additional 28 clinical advisers – new 
posts – were recruited to support this new process to ensure people get the right response 
the first time.  

The next phase of the framework was introduced in December, following a clinical review of 
the amber and green categories of call. A new orange  – time-sensitive response category 
was  introduced.  This  was  designed  to  ensure  people  with  conditions  such  as  suspected 
stroke or STEMI are identified earlier through enhanced clinical screening in the 999 contact 
centres to receive a faster, more appropriate ambulance response, and rapid transport to 
specialist care.  

 The new framework also increases opportunities to better understand patient outcomes and 
experience  by  broadening  measurement  beyond  initial  response  times  to  include  more 
clinically meaningful metrics, such as call-to-door times. The intent is to enable clearer insight 
into the timeliness and quality of care delivered to patients with serious and time-sensitive 
conditions, including stroke, to drive quality improvement.  

The changes are being tested for 12 months and will be thoroughly evaluated.   

I understand that Mrs Trish Gaskell, the Trust’s former Solicitor, had made the offer to you 
to  attend  the  Clinical  Contact  Centre  now  located  in  St  Asaph,  to  observe  firsthand  the 
changes that have been made to our response model. 

Improving ambulance patient handover performance  

All  health  boards  are  expected  to  deliver  the  Ambulance  Patient  Handover  Guidance, 
published by the Welsh Government. This was updated in January 2026 and issued to health 
boards for immediate delivery. I enclose a copy of that guidance for your reference. 

This reinforces that ambulance patient handover is a whole system responsibility, requiring 
co-ordinated  action  across  all  parts  of  the  NHS  and  aligned  to  existing  escalation 
arrangements.  It  also  expects  a  more  consistent  approach  to  monitoring,  assurance,  and 
accountability,  enabling  system  leaders  to  identify  and  address  the  underlying  causes  of 
handover delays rather than managing the symptoms alone.  

Last year the Cabinet  Secretary  for Health and Social Care  set up  a clinically-led National 
Handover-45 Taskforce to support delivery of a recommendation made by the Ministerial 
Advisory  Group  on  NHS  Performance  and  Productivity  to  eliminate  ambulance  patient 
handover delays of more than 45 minutes. The taskforce has brought together senior clinical, 
operational  and  system  leaders  from  across  NHS  Wales  and  has  overseen  focused 
improvement activity, shared good practice, and provided national clinical leadership on safe 
and timely handover.  

Its  work  has  helped  to  strengthen  understanding  about  why  handover  delays  happen, 
reinforced the importance of whole-system flow, and supported measurable improvements 
in handover performance across a majority of hospital sites in Wales.  

I enclose a copy of the Ambulance Handover Accelerated Design Events Integrated Thematic 
Summary,  which  provides  more  detail  and  context  regarding  the  National  Handover-45 
work.  

I appreciate that these broad system-based actions will not diminish the loss experienced by 
Mrs. Parkhill’s family. I am genuinely sorry that we were not able to deliver the service I am 
committed to offering to them. 

If you wish to take up the offer of visiting our clinical contact centre (now based at St Asaph) 
, Legal Services Manager, who will be happy to arrange this. 
please contact 
I understand that the Trust’s Executive Director of Nursing,
 has also offered 
to meet with you recently, and this can also be arranged via 

 Yours sincerely  

CHIEF EXECUTIVE 

Encl: Ambulance Patient Handover Guidance 

ADE integrated thematic summary report