Response to Coroner RE: Peter Thompson Thank you for the RegulaƟon 28 Report dated 13 January 2026. We take the findings extremely seriously and are commiƩed to implemenƟng all necessary measures to safeguard residents and prevent future deaths. Our response addresses the concerns raised regarding handover processes and blood glucose monitoring for diabeƟc residents.
1. Handover Processes Bank Close House has always operated a structured handover system between every shiŌ. This includes:
• A face to face handover meeƟng at the end and start of each shiŌ.
• A wriƩen daily handover sheet, completed for every shiŌ, summarising key observaƟons, concerns, and updates for each resident.
• An electronic handover record on PCS, which complements the wriƩen notes and provides a digital record of ongoing care needs, changes in condiƟon, and escalaƟon acƟons. The wriƩen daily handover sheet explicitly directs staff to review digital notes on PCS, ensuring that all staff have access to a complete and up to date picture of each resident’s condiƟon. Samples of both the wriƩen and electronic handover formats have been provided. It is important to note that the former manager was present at these handovers every day, parƟcipaƟng in and overseeing the exchange of informaƟon between shiŌs. This ensured that concerns, changes in condiƟon, and ongoing issues were discussed verbally in addiƟon to being recorded. We acknowledge the coroner’s concern that the records reviewed during the inquest did not fully reflect the level of discussion or the priority of concerns during handover. In response, we have strengthened documentaƟon expectaƟons to ensure that all verbal handover informaƟon is consistently and accurately recorded.
2. Blood Glucose Monitoring for DiabeƟc Residents The coroner’s report states that Bank Close House should be carrying out blood glucose tesƟng for diabeƟc residents. Historically, the home has been advised by both the Ageing Well Team and the GP PracƟce Advanced Nurse PracƟƟoner that care home staff should not undertake blood glucose tesƟng. This guidance has been consistent and shaped our pracƟce, please see aƩached care plans with entries added in with instrucƟons from ageing well team. Following the coroner’s findings:
• The Ageing Well Team has now supplied blood glucose monitoring machines for all diabeƟc residents.
• They remain uncertain about who will be responsible for delivering the required training and competency assessments for care home staff.
• We are awaiƟng formal confirmaƟon from external healthcare professionals so that we can implement blood glucose tesƟng safely and in line with clinical governance requirements.

UnƟl staff are trained and signed off as competent, all concerns regarding a diabeƟc resident’s health will conƟnue to be escalated to external professionals, who will carry out blood glucose tesƟng as needed.
3. Lessons Learned The incident has highlighted several important learning points:
• Despite mulƟple visits and telephone conversaƟons with District Nurses and the Advanced Nurse PracƟƟoner in the days prior to hospital admission, no blood glucose test was taken or recommended by any external professionals unƟl the day of admission. As an interim measure, staff have been instructed that any concerns about a diabeƟc resident’s health must include a request for a blood glucose test from external healthcare professionals unƟl training and competencies are completed by care staff.
4. AcƟons Implemented to Prevent Recurrence The following acƟons have been taken:
• GP surgeries have been asked to provide each diabeƟc resident’s HbA1c level, ensuring staff have baseline informaƟon about long term glucose control.
• Staff have been instructed to request a blood glucose test immediately from external professionals if a diabeƟc resident shows signs of illness, infecƟon, reduced intake, or any other concerning change.
• Blood glucose monitoring equipment has been provided by the Ageing Well Team and is now on site, however We are sƟll awaiƟng confirmaƟon of:
• who will deliver blood glucose tesƟng training,
• what competencies will be required,
• and what the ongoing expectaƟons will be for care home staff. Training will be implemented immediately once this informaƟon is provided.
5. Outcome and Ongoing Monitoring All staff complete diabetes awareness training, ensuring they understand the risks associated with illness, dehydraƟon, and hyperglycaemic emergencies. We are currently awaiƟng:
• formal training in blood glucose tesƟng,
• competency assessments,
• and clear guidance from external medical professionals regarding expectaƟons and clinical governance. UnƟl this is provided, we will conƟnue to escalate all diabeƟc health concerns to external clinicians for blood glucose tesƟng. Further monitoring and review will conƟnue unƟl the training pathway and responsibiliƟes are formally confirmed.