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

Action Taken Date of Action 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.
05.09.2025

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.

Created by: Mariana Costa (Home Manager) Date: 23/10/2025 Next Review Date: 23/10/2026 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
36.0–37.5°C ≥37.8°C or ≤36°C Pulse 60–100 bpm <50 or >110 bpm, irregular rhythm Blood Pressure 100–140 / 60–90 mmHg Systolic <100 or >180; Diastolic <60 or >100 Respiratory Rate 12–20 breaths/min <12 or >22 Oxygen Saturation (SpO₂) ≥94% (or resident baseline) <94% or 3% below baseline Consciousness Alert, responsive 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 Availability 1￿⃣ Registered Nurse (RN) On site 24/7 2￿⃣ Clinical Lead On site and On call 24/7 3￿⃣ Home Manager / Deputy Manager On site and On call 24/7 4￿⃣ Emergency Services (999) Immediate for life-threatening emergencies 5￿⃣ GP / NHS 111 As advised by RN or management
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.