Dear Ms Bailey Thank you for your letter of 14 March 2016 and accompanying report made under the relevant sections of the Coroners and Justice Act 2009 and the Coroners (Investigations) Regulations 2013 referring t0 your investigations into the death of Margaret Metcalfe and concerns about the potential for future deaths from falls. am responding on behalf of The Manager; Rosedale Centre, a Stockton-on-Tees Borough Council facility for the rehabilitation and assessment of adults. First of all would Iike t0 convey the sincere condolences of the Rosedale Centre management and staff to the family of Mrs Metcalfe following her death in November 2015. Background Mrs Metcalfe was a client in the Rosedale Centre between 7ih October 2015 and 25" October 2015, the day she was transferred back to the University Hospital of North Tees following a fall in the corridor outside her room: She had been admitted t0 the Rosedale Centre for rehabilitation support from the University Hospital of North Tees on 7ih October 2016 having been given treatment whilst in hospital for a fracture to her right neck of femur following an accidental fall at home She was allocated Room 8 on the Laurels Rehabilitation Unit with objectives to increase confidence, develop mobility and support transfers: Rehabilitation and assessment support at the Rosedale Centre is provided free of charge for up to six weeks to people requiring this level of support; usually on discharge from a hospital setting but occasionally to prevent an admission to hospital. Mrs Metcalfe was described as "out of sorts" on the guh October 2015 and found to have a Urinary Tract Infection, which was treated with antibiotics: During her stay, there were two occasions when Mrs Metcalfe was found by staff on the ie. on gth October 2015 and 11th October 2015. Neither incident was observed by staff: Mrs Metcalfe told staff that on the first occasion she had put herself on the floor by slipping down the side of the wardrobe The second occasion was when she rolled out of bed, On neither occasion did she sustain any injury. At these times the client's risk assessment was checked by the therapy staff and amended accordingly: Private & Confidential Ms C. Bailey Acting Senior Coroner for Teesside The Coroners Service Middlesbrough Town Hall Albert Road Middlesbrough TS1 2QJ 2016 Big floor,

Stockton-on-Tees BOROUGH COUNCIL Adult Services Big plans for the care we provide During her stay other concerns were being expressed about Mrs Metcalfe by staff, including her loss of weight; which was assessed by the Health Trust's Dietician and her confusion, which was assessed by her GP and apart from low blood pressure could find no physical reason for the confusion: A referral was made by her GP for an assessment to the Community Psychiatric nursing service on 16th October 2015 and the nurse visited on 24ih October 2015. A Social Care review was held on 22nd October 2015 with Mrs Metcalfe's social worker present and a decision taken to recommend a 24hr residential care placement: Technology Support The Rosedale Centre provides different levels of technology support to assist staff with the care of people. The Centre caters for a range of people with varying health and social care needs There are 44 separate individual bedrooms situated on four units of 10 or 12 beds. Each unit is staffed 24hrs each with at least two care staff on duty on each unit between the hours f 7.30am
9.45pm (8 in total) and one waking care staff on on each unit during the night (4 in total): There are additional management and coordinator staff and staff employed to undertake therapy support tasks. The Centre also employs housekeepers, catering and administrative staff . The staffing levels meet the requirements of the Care Quality Commission who have regulatory responsibility for the Centre. All rooms have access to the "Nurse Call" system, a hard wired call system linking a hand operated call "button" to four individual sub control panels, one on each unit; and a central control panel located outside the main office. Each sub control panel and the central control panel receive information visually and audibly and each bedroom has a light outside the door offering a visual indication that a call has been made from that room. It is therefore possible to be aware of any call made by a person from any bedroom at any time: The person making the call from a bedroom has access to both a short and long cord with the call button located on the end of the cord Once made the call can only be cancelled from the point of contact i.e. in the room the call was made. It is not possible to cancel the calls from either the sub control panel or central control panel: All 44 beds at the Rosedale Centre are fitted with a "Bed Sensor" . This is a Telecare Overlay system which monitors individual beds and therefore people; that when activated raises alerts via Stockton-on-Tees Borough Councils 24hour Care Call control centre to on-site care staff: The system is configured t0 raise alerts between the hours of 9pm and 6am, seven a week; In the event the person has left their bed and not returned within a 20-minute period, the on-site staff receive an alert via a mobile phone call from the Care Call centre . It often picks up that a person has moved to the chair in the room or on occasion has fallen from their bed. An additional service known as the "Care Assist" system was introduced in May 2013 at the request of occupational therapy staff for people assessed as at risk of falling and requiring a 24hr monitoring service. This is a separate sensor which replaces the Telecare Overlay: A pilot scheme carried out in different care homes had already shown reductions in the number of people falling using this system: This additional equipment provides & bespoke package for an individual person. Those people determined at higher risk have their Bed Sensor deactivated from the Telecare Overlay and routed t0 a Care Assist pager: 2 day - duty days

Stockton-on-Tees BOROUGH COUNCIL Adult Services plans for the care we provide The Care Assist system offers linked bed and chair sensors in a bedroom, connected together to a signalling device known as a universal sensor: When the bed or chair sensor is activated it uses the universal sensor to send a signal to a portable pager: Individual Care Assist devices are fitted by the Council's Care Call installer. The device sends a signal to the pagers which omit a and vibrate to alert the staff member of the exact location the alert is from. All alerts are date and time stamped giving sensor ID number and person's name and room number: The Council's Care Call service has an equipment database, which enables tracking of where equipment is located by its serial numbers_ use log sheets completed by the installer for every installation: The Care Assist pager equipment works using a rechargeable battery: It will work for up to 12 hours on one full charge. Each pager requires a period of 2-3 hours Of charging each and failure to top up the pagers charge will result in the pager not working properly: The pagers require careful handling and are not shock or water proof: The pager stores the alerts of the last 256 events received and it is possible to retrieve the data PC connected t0 a Care Assist's USB port: Mrs Metcalfe's technology support Mrs Metcalfe was allocated Room 8 in Laurels unit. On admission she was shown how t0 operate the Nurse Call system and had the Bed Sensor available. Following the two occasions she was found on the floor it was assessed by the Therapy staff that having a Care Assist system installed would help reduce the risk of a fall. From available records held by Care Call the Assist equipment was installed on 114 October 2015 at 5.3Opm by Care Call personnel. On 17th October and 18lh October 2015 Care Call staff visited to reposition the universal sensor. Fall event 25th October 2015 On 25th October 2015 at 4.30am Mrs Metcalfe was found on the floor of the corridor outside her bedroom. The night staff member was alerted to the sound of Mrs Metcalfe falling to the floor. Her incident report indicated she had sustained injuries: A call was immediately made t0 the 111 service for advice and an ambulance was subsequently requested: At 6.30am the ambulance arrived and Mrs Metcalfe was taken to the University Hospital of North Tees Accident & Emergency Department and thereafter admitted to hospital; An internal investigation has been carried out by the Manager of the Rosedale Centre based on the Coroner's Report of 14th March 2016. The focus of the investigation was the fact the fitted Care Assist system did not alert the night staff member to Mrs Metcalfe leaving her bed: Checks have subsequently been made on the Care Assist equipment to see if a record could be retrieved for the 25th October 2015. Unfortunately the data information for that date is no longer available on the device as it had over written the 256 events activation memory: Evidence from the staff member on duty at the time of Mrs Metcalfe's fall was given some four months after the event; Unfortunately at the time of the accident only limited notes of the incident were recorded in the staff report book. Details of the activity leading up to the point Mrs Metcalfe was found on the floor have been difficult to recollect: The fact Mrs Metcalfe was able to leave her bedroom without the Assist pager going off may be down to the battery not having been charged properly i.e. for the required length of time. We know from the guidance that failure to top up the pager's charge fully will result in the pager not working properly: Big bleep the They day fullly - using Care Care

Stockton-on-Tees BOROUGH COUNCIL Adult Services Big plans for the care we provide Subsequent Actions Taken In response to your request that action be taken to prevent future deaths from falls the following actions have been taken and a written procedure implemented:
1. The four Care Assist pagers available within the Rosedale Centre have been fully checked alongside their separate charging units_ 2 The charging units have been moved from the kitchen to the main office to allow for management oversight of the equipment:
3. Each of the four Care Assist pagers has been re-labelled clearly to identify which unit it is allocated to and which charging system it belongs to.
4. Each Unit Manager has been reminded about the Care Assist procedure and have discussed with team members the procedure.
5. Each person will be risk assessed by the Therapy Team to identify who will be allocated a Care Assist unit:
6. Staff will be reminded by the Therapy Team of the need to be extra vigilant and give special instructions to minimise risks until Care Assist equipment is fitted: At the request of the Therapy team the SBC Care Call team will fit each Care Assist system and check it is functioning appropriately:
8. At the start of each shift staff are responsible for checking which bedrooms people have a Care Assist unit fitted to the bedlchair. This is covered on the staff handover sheet used for transferring information between shift changes. 9 At the start of the shift staff responsible for the Unit will agree who is to carry the Care Assist pager unless it is the night staff member who will always carry the pager (subject to Care Assist used for any person):
10. The staff allocated the Care Assist pager are to ensure it is re-charged during periods when people are out of their bedroom (i.e. in the dining lounge areas)
11. A record of this will be made by the responsible staff member in the daily care record:
12. The staff allocated the Assist pager are to ensure it is with them at all times and handed over to a colleague when they leave the unit:
13. During the time a person is in their bedroom and Care Assist is used staff are responsible for checking the Care Assist unit is working_
14. Staff responsible for the Care Assist pager are t0 make appropriate notes in the care records
15. Staff are required to respond appropriately and in a timely manner t0 alerts triggered to offer assistance to person
16. problems identified with the Care Assist pager will be reported to the Duty Manager immediately and documented.
17. Each individual person's Care Plan and Kardex record will document the use of the Care Assist equipment:
18. The Manager has an audit process in place to check the Care Assist equipment on a monthly basis_ Clearly steps are taken by the Rosedale Centre to use available technology to assist staff in receiving timely information as to the movements of people identified to be at risk The equipment being used is not something that can guarantee immediate action by the staff even when alerts are notified Staff on duty have a responsibility for all people on the unit are allocated. Generally staff are supporting people with a full range of daily personal care tasks and can be called upon at being Care being being the Any being they

Stockton-on-Tees BOROUGH COUNCIL Adult Services Big plans for the care we provide any time t0 provide assistance_ There are times when people are required to wait for staff to be available. This is especially so during the time shifts but equally staff can be busy during the night time ensuring people are appropriately assisted in accordance with personal wishes hope this report and details of the actions taken will provide assurance that everything is being done to support people at risk of falling: We take our responsibilities seriously and work with people to encourage maximisation of their independence. This process requires regular assessment and risk management