John Fisher

Coastal Homecare - Hove Branch 
Coastal Homecare (Hove) Ltd. 
78 Goldstone Villas  
Hove  
East Sussex 
BN3 3RU  

12th May 2026 

Karen Taylor  
Assistant Coroner for West Sussex, Brighton & Hove  
Woodvale, Lewes Road, Brighton  
East Sussex, BN2 3QB  

Dear Coroner,  

RE: Regulation 28 Report to Prevent Future Deaths - John Malcolm Fisher, who died at the 
Royal Sussex County Hospital on 4th May 2025.  

Thank you for your report to Prevent Future Deaths dated 19th March 2026 concerning the death 
of John Malcolm Fisher on 4th May 2025. In advance of responding to the concerns raised I would 
like to express my condolences to Mr Fisher’s family and loved ones. Coastal Homecare would 
like to reassure the family and yourself that the concerns relating to Mr Fisher’s care have been 
listened to and reflected upon. 

Your  Report  raised  concerns  regarding  the  safe  transfer,  reconciliation,  and  verification  of 
medication information when care is handed over between hospital services, Urgent Community 
Response  teams,  pharmacies,  GPs,  and  domiciliary  care  providers  operating  within  the 
community. 

You asked that consideration be given to strengthening guidance, communication pathways, and 
verification  processes  to  support  community-based  care  providers  responsible  for  delivering 
medication administration within non-clinical home environments. In particular, concerns were 
identified regarding the reliance by care organisations on handwritten medication administration 
records  when  onboarding  patients,  the  absence  of  a  fully  integrated  health  and  social  care 
system,  and  the  lack  of  clear  information  relating  to  current  prescribed  medication,  dosage, 
timing, formulation, and method of dispensing available to care organisations. Concerns were 
also  raised  regarding  the  absence  of  robust  cross-checking  arrangements  during  transfers  of 
care  between  agencies  and  limited  liaison  with  community  pharmacy  services  where 
discrepancies or uncertainty existed. 

1 

 
 
 
 
 You further highlighted the importance of ensuring that community care providers have sufficient 
safeguards, escalation procedures, and access to accurate medication information to reduce 
the  risk  of  discontinued  medication  being  administered  or  essential  medication  being 
inadvertently omitted during transitions of care. 

Please  see  the  enclosed  response  from  Coastal  Homecare,  setting  out  the  actions  taken 
following the coroner’s concerns, including the review of policies, strengthening of medication 
verification  processes,  implementation  of  additional  safeguards,  and  wider  organisational 
learning identified through this incident. 

Response from Coastal Homecare  

We extend our sincere condolences to Mr Fisher’s family and loved ones at this difficult time. 
Coastal Homecare has been providing domiciliary care services across Brighton & Hove for more 
than 10-years and has supported in excess of 4,000 people within the local community during 
that time. Everyone working within the care profession does so with the intention of providing 
safe, compassionate, and person-centred support. The safety and wellbeing of the people we 
care for remains our highest priority, and we are committed to working openly and collaboratively 
with our health and social care partners to ensure that learning is identified, shared, and acted 
upon. 

Our  involvement  in  Mr  Fisher’s  care  was  for  6 days  between  16  April  2025 and  21  April  2025. 
During  this  period,  we  provided  three  care visits  per  day,  delivered by  two  care  assistants, to 
support with; personal care, medication administration, and general welfare monitoring.  

As  a domiciliary  care provider,  we support people who choose to remain living independently 
within their own homes. Unlike a clinical setting, home care is delivered within an individual’s 
personal home environment, where information, medicines, and support arrangements are often 
managed across multiple services and systems. This can create additional challenges and risks 
in  relation  to  communication,  oversight,  and  the  timely  verification  of  clinical  information.  In 
carrying  out  our  role,  we  therefore  rely  upon  the  accuracy  and  completeness  of  information 
shared with us at the point of referral, assessment, and transfer of care. 

In  this  case,  we  acknowledge  that  the  medication  information  available  to  us  at  the 
commencement of the package of care did not fully reflect Mr Fisher’s current needs, and that 
we accepted a medication summary and paper Medication Administration Record (MAR), issued 
by hospital services without sufficient further verification. 

We  had  previously  supported  Mr  Fisher  as  part  of  our  longstanding  role  within  the  local 
community  working  alongside  NHS  Sussex  Community  Foundation  Trust  (SCFT),  Urgent 
Community  Response  (UCR).  Upon  resumption  of  care,  staff  relied  upon  the  information 
available  at  the  time,  including  the  documentation  provided  and  discussions  held  during 
handover. Considering the coroner’s findings, we are reviewing our safeguards and verification 
processes to determine where further improvements may be appropriate. 

Our  focus  since  receiving  the  coroner’s  report  has  been  on  careful  reflection,  organisational 
learning,  and  strengthening  our  practice  to  reduce  the  risk  of  similar  circumstances  arising 
during  handover  in  the  future.  We  have  undertaken  a  review  of  our  policies,  procedures,  and 
operational processes and have introduced several additional safeguards. 

2 

 
 Implementation of Safeguards 

The following changes have now been implemented: 

●  At the commencement of all new packages of care, staff now take photographic records 
of all medications present within the home at the point of assessment and onboarding. 
This  additional  safeguard  goes  beyond  previous  internal  practice  and  is  intended  to 
support  more  accurate  reconciliation  of  medication  information  and  escalation  of 
discrepancies. 

●  We have strengthened our medication auditing and handover processes. Staff are now 
required  to  cross-check  medicines  currently  present  in  the  home  against  available 
prescribing  records,  previous  administration  records,  and  referral  documentation  to 
identify any inconsistencies at the earliest opportunity. 

●  At the time Mr Fisher was receiving support from our service, GP Connect access was not 
available  to  our  digital  platform.  Since  October  2025,  we  have  fully  integrated  GP 
Connect to our digital platform, and into current practice as an additional safeguard to 
support  safer  medication  management  and  continuity  of  care.  Subject  to  appropriate 
consent arrangements and patient opt-out rights, authorised staff are now able to review 
GP medication summaries to verify prescribed medicines and identify recent medication 
changes  during  referral, assessment,  and handover  processes.  This  has  strengthened 
our ability to cross-check medication information and identify discrepancies at an early 
stage. We recognise, however, that some medication changes initiated within hospital 
settings, Urgent Community Response services, or other secondary care pathways may 
not always be immediately reflected within GP Connect records. Our revised procedures 
therefore  also  require 
including 
pharmacists,  and  specialist  teams,  where  appropriate,  to  support  safe  and  accurate 
medication management. 

liaison  with  relevant  healthcare  professionals, 

●  We  now  formally  record  the  dispensing  pharmacy  responsible  for  each  person’s 
medication  and  have  strengthened  escalation  procedures  requiring  liaison,  where 
appropriate,  with  pharmacists,  GPs,  hospital-based  community  services,  specialist 
nursing teams, and other relevant healthcare professionals to support safe continuity of 
care and  accurate  medication management. While we work collaboratively with these 
services, we recognise that health and social care systems are not fully integrated and 
information  is  often  held  across  separate  records  and  organisations.  Our  revised 
procedures  are  therefore  intended  to  improve  communication,  verification,  and 
escalation where discrepancies or uncertainties are identified. 

●  All staff are now required to complete additional Epilepsy Awareness training as part of 
our ongoing commitment to strengthening knowledge, understanding, and safe practice 
across the service. Additionally, representatives of the organisation have attended the 
Local  Authority’s  Medication  Adults:  Epilepsy  Awareness,  Seizure  Management  and 
Buccal Midazolam training to further enhance our medication management procedures 
though continued learning.  

We  also  recognise  the  importance  of  openness,  reflection,  and  continuous  improvement 
following this tragic event. Mr Fisher had a longstanding diagnosis of epilepsy, a condition which 

3 

 
 carries  an  inherent  risk  of  sudden  and  potentially  fatal  seizures.  We  understand  from  the 
information  available  that  there  had  been  periods  where  prescribed  epilepsy  medication 
management had varied. We do not seek to comment on medical causation beyond the findings 
made  by  the  coroner.  However,  we  remain  fully  committed  to  learning  from  this  case, 
strengthening staff oversight and training, and continuing to work collaboratively with health and 
social care professionals to promote the safest possible care for the people we support. 

Care Quality Commission Inspection and Feedback 

Since this incident, Coastal Homecare has also undergone an in-person inspection by the Care 
Quality Commission (CQC). Initial post-inspection feedback provided to the service identified 
several areas of positive practice and acknowledged the organisation’s commitment to learning, 
safeguarding, and continuous improvement. 

The  CQC  noted  that  people  were  safe  in  the  care  of  Coastal  Homecare  and  found  that 
safeguarding  concerns,  incidents,  and  risks  were  appropriately  documented,  escalated,  and 
monitored for patterns or trends, no areas of concern were identified in the initial feedback. The 
Inspector also recognised that learning opportunities were actively identified and used to reduce 
the risk of recurrence. Feedback highlighted positive partnership working with external agencies 
and  healthcare  professionals  to  help  keep  people  safe,  alongside  robust  recruitment,  staff 
training, and governance arrangements. 

The  inspection  further  recognised  that  medicines  were  being  managed  safely  and  that 
strengthened  quality  assurance  processes  provided  effective  oversight  by  management  and 
office staff. The Inspector found that care plans were regularly reviewed and updated, referrals 
to  external  professionals  were  made  appropriately,  and  staff  demonstrated  a  good 
understanding  of  areas  including  mental  capacity,  safeguarding  responsibilities,  and  person-
centred care. 

Importantly, the CQC identified a strong organisational culture centred on openness, reflection, 
learning,  and  staff  support.  Inspectors  noted  that  staff  felt  confident  raising  concerns  and 
described  management  as  approachable  and  responsive.  Feedback  from  people  using  the 
service  and  their  relatives  described  staff  as  kind,  caring,  and  respectful,  with  positive 
relationships developed between care staff and the people they supported. 

We  are  currently  awaiting  publication  of the  CQC’s full  inspection  report  and  will  continue  to 
review  and  reflect  upon  any  further  findings  or  recommendations  once  available.  We  remain 
committed  to  engaging  openly  with  regulators  and  to  ensuring  that  any  additional  learning 
identified is incorporated into our ongoing service improvement work. 

We hope that the actions taken, and the learning identified through this process, will contribute 
positively towards reducing the risk of similar circumstances occurring in the future. 

Yours Sincerely,  

Registered Manager  
Coastal Homecare - Hove Branch   

4

Sussex Community NHS Foundation Trust 
Brighton General Hospital 
Elm Grove, Brighton 
East Sussex 
BN2 3EW 

Private & Confidential 

Karen Taylor 
Assistant Coroner 
West Sussex, Brighton and Hove 
Chart Way, Horsham 
West Sussex 
RH12 1XH 

Date: 11th May 2026 

Re: Regulation 28 Report to Prevent Future Deaths – John Malcolm Fisher (deceased) 
Date of Report: 19 March 2026 

Dear Ms Taylor, 

Thank you for your Regulation 28 Report to Prevent Future Deaths following the inquest into the death 
of Mr John Malcolm Fisher on 11 March 2026. I would like to begin by extending my sincere 
condolences to Mr Fisher’s family. I am grateful for the careful consideration given by the Court and 
for the opportunity to respond on behalf of Sussex Community NHS Foundation Trust (SCFT). 

I confirm receipt of your report and set out below SCFT’s response to the matters of concern raised, 
including actions already taken and further actions planned, in accordance with Regulation 29 of the 
Coroners (Investigations) Regulations 2013. 

Context and Acknowledgement of the Coroner’s Findings 

We note the Coroner’s conclusion that Mr Fisher died from natural causes, namely status epilepticus 
due to epilepsy, and that no single failing or event was identified as causative of death. We further 
acknowledge the Coroner’s view that, notwithstanding this conclusion, there remains a risk that 
future deaths could occur unless action is taken to strengthen medicines management, 
documentation, and handover processes across community services. 

SCFT fully accepts the importance of addressing system vulnerabilities identified during the inquest 
and shares the Coroner’s commitment to reducing the risk of similar issues affecting other patients in 
the future. 

 
 
 
 
 
 Internal Review and Learning 

Following receipt of the Regulation 28 report, SCFT commissioned an internal Rapid Review under the 
Patient Safety Incident Response Framework (PSIRF), focusing on the Urgent Community Response 
(UCR) service involvement between 8 and 15 April 2025 and the subsequent transfer of care. 

The review confirmed that: 

•  The initial Medication Administration Record (MAR) chart produced by UCR on 9 April 2025 
accurately reflected the GP summary of prescribed medications available at that time. 
•  A vulnerability arose when phenobarbital, which had recently been dispensed and remained 
physically present in the home, was incorrectly added to the MAR chart on 11 April 2025 
following escalation of the discrepancy, without gaining confirmation from the GP. 

•  There is a wider system risk at interfaces of care, particularly where discontinued medicines 
remain in patients’ homes and where care transfers rely on documentation that may be 
misinterpreted or used beyond its intended purpose. 

The review did not identify a single system failure but highlighted opportunities to strengthen 
medicines reconciliation, escalation, and handover clarity across service boundaries. 

Response to the Coroner’s Specific Matters of Concern 

1. Accuracy and Reliability of Medicines Records 

Action taken and planned: 

•  SCFT has undertaken a formal review of its MAR chart Standard Operating Procedure (SOP) for 

UCR and Home First services. 

•  The SOP is being updated to include explicit guidance on the management of recently 

discontinued medications that remain physically present in the home, including a mandatory 
second check with the GP where discrepancies arise. 

•  Clear escalation pathways have been strengthened, including referral to senior clinicians and 

SCFT pharmacy support for complex medicines reconciliation. 

Timetable: 

•  Updated SOP to be ratified by early June 2026.  
•  Staff briefings and training aligned to the revised SOP to commence immediately following 

approval. 

 
 
 
 
 
 
 
 2. Use of Outdated or Unverified Medication Information 

Actions taken: 

•  Since October 2025, SCFT staff have access to shared care records via the Plexus system 
(which links digital care records across Sussex GP’s, hospital and community healthcare 
services as well as local authorities), enabling real-time access to GP medication summaries 
and reducing reliance on emailed or static information. 

•  Pharmacy support is now embedded within the UCR/General Virtual Ward model, providing 

timely expert advice where medication regimes are complex or unclear.  

•  These controls are already in place and subject to ongoing audit and governance through 

Medicines Management and clinical quality forums. 

3. Medicines Information Provided at Handover to Care Agencies 

Action taken and planned: 

•  UCR referral documentation is being revised to clearly reinforce current agreements that 

receiving care agencies must undertake their own medicines reconciliation directly with the 
prescriber and community pharmacy. 

•  The referral documentation will explicitly state that UCR MAR charts are for SCFT staff use only 
and are not intended to be relied upon by external providers as a definitive medicines record. 

•  We have now added further wording to the referral proforma as follows: 

o  “Receiving care agencies must undertake their own medicines reconciliation directly 

with the prescriber and pharmacy. UCR MAR charts are for SCFT staff use only and are 
not intended to be relied upon by external providers as a definitive medicines record.” 

Timetable: 

•  Revised referral documentation to be implemented by May 2026. 

4. Lack of Robust Cross-Checking at Interfaces of Care 

Action taken and planned: 

•  SCFT has strengthened expectations within referral pathways that medicines reconciliation 
must be confirmed at transitions of care, particularly where responsibility for medicines 
administration is transferring. 

•  A themed review of medication incidents involving MAR charts within UCR is underway to 

inform ongoing quality improvement, training, and assurance. 

 
 
 
 
 
 
 
 Timetable: 

•  Themed review findings to be reported through Trust governance structures by the end of June 
2026, with resulting actions tracked through the Trust Safety Improvement Plan and Trust 
Quality Governance framework. 

Assurance and Governance 

All actions described above are being monitored through SCFT’s established clinical governance, 
medicines management, and quality assurance arrangements. Risks relating to medicines 
administration and MAR chart processes are recorded on the Trust risk register with ongoing senior 
oversight. 

SCFT will continue to work collaboratively with primary care, social care, community pharmacy, and 
domiciliary care providers to support safer transitions of care and shared learning across 
organisational boundaries. 

Closing 

I trust this response provides assurance that SCFT has carefully considered the concerns raised by 
the Coroner and has taken, and will continue to take, proportionate and meaningful action to reduce 
the risk of similar occurrences in the future. 

Please do not hesitate to contact me should you require any further clarification or information. 

Yours sincerely, 

Chief Executive 
Sussex Community NHS Foundation Trust