Dear HM Assistant Coroner Sarah Wood,

Regulation 28 Report following the inquest into the death of Mr Ronald Colin Nelson

Thank you for bringing the Regulation 28 Report to our attention following the inquest into the death of Mr Ronald Colin Nelson who died on 26th of January 2025 at the Queens Medical Centre, Nottingham. We acknowledge the concerns you have raised and appreciate the opportunity to respond.

We would like to express our sincere condolences to Mr Nelson’s family and loved ones following his death.

We have noted the matters of concerns listed below, in respect of Mulberry Court Care Home, 61 Darnhall Crescent, Bilborough, Nottingham, NG8 4QA:

i) That there remain potential issues of poor record keeping. ii) There are concerns over the level of compliance of care plans. We wrote to the Nominated Individual of Mulberry Court Care Home on 22 January 2026, requiring them to set out in writing, within 7 days, the action taken to date and any further planned action to meet the serious concerns identified during the inquest and the two points listed above. We received a response by return, 22 January 2026 which informed us of the following:

• The Nominated Individual had been in post since 19 July 2025;

• The Nominated Individual had instigated on 19 January 2026, a second independent investigation to determine the short comings in connection to the care of Mr Ronald Colin Nelson. This was due to conclude by the end of February 2026 and that a copy would be shared with the Care Quality Commission (CQC) will receive a copy of this.
• The Nominated Individual submitted to CQC on 28 January 2026, a service improvement plan.
• The Nominated Individual informed CQC that they had made a formal request to the Integrated Care Board for an unannounced quality audit to be undertaken ‘in the very near future’. The CQC held a Decision-Making Meeting (DMM) on 27 January 2026 on receipt of the Prevention of Future Deaths report, to agree next steps to respond to the concerns raised.

Mulberry Court Care Home was previously inspected in January 2019, with the report published in March 2019. The service was rated good overall with the key questions of Safe, Effective, Caring and Well Led rated good. The key question of responsive was rated outstanding. In line with The CQC’s current Adult Social Care (ASC) assessment priorities, Mulberry Court Care Home met the priority of a service not assessed within 6 years.

An unannounced assessment was conducted at Mulberry Court Care Home on 17 and 18 February 2026. Further off-site assessment work continued such as reviewing documents and speaking with people. This assessment looked at all key questions to determine if Mulberry Court Care Home is safe, effective, caring, responsive and well-led. Details of the assessment framework used to undertake this assessment can be found here: Assessment - Care Quality Commission.

The assessment reviewed a range of documents, systems and processes used by Mulberry Court Care Home, interviewed staff, observed clinical practice and interactions by staff and spoke with those who used the service. This has allowed CQC to determine if the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (“The Regulations”) are complied with. We have made a judgement on the standard of care including but not limited to the concerns raised within the Prevention of Future Deaths report.

The Regulations under which care planning and record keeping are reviewed are:

Regulation 9: Person-centred care - Care Quality Commission

To meet the Regulations, providers must make sure that people using a service have care or treatment that is personalised specifically for them. This regulation describes the action that providers must take to make sure that each person receives appropriate person-centred care and treatment that is based on an assessment of their needs and preferences.

Regulation 12: Safe care and treatment - Care Quality Commission

Providers must prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Providers must assess the risks to people's health and safety during any care or treatment and make sure that staff have the qualifications, competence, skills and experience to keep people safe. Regulation 17: Good governance - Care Quality Commission

Providers must securely maintain accurate, complete and detailed records in respect of each person using the service.

We found that record keeping and care planning at Mulberry Court Care Home is in line with the regulations. The provider ensured that daily records, care plans, risk assessments and contemporaneous records in relation to care delivery were detailed, individualised updated and reviewed regularly. This meant staff knew how to care for people in the service.

Staff were knowledgeable about how to care for people in the service, because they had read and understood health records, including care plans and risk assessments, and carried out care in line with guidance and instructions in the records.

Staff had received training in tissue viability: pressure injuries training, wound healing (which included assessment, treatment and dressing). Care staff were all either trained to National Vocational Qualifications (NVQ) Level 2 or 3 or had completed a Care Certificate which included positional care, nutrition and hydration care as well as safe food handling.

We are assured that the service improvement plan to address concerns raised by you in the Prevention of Future Deaths report has been shared with staff across the service and actioned. There was a strong focus on the actions and how the service will meet them. There was a clear focus on safety. There was evidence of how lessons were learned from the death of Mr Nelson. Team meetings, reflective practice, daily huddles, handover meetings and clinical meetings were embedded.

Our assessment has concluded, however, the report is in draft and will require the standard quality assurance and factual accuracy review by the provider. Therefore, the report will not be published until after the deadline for this response. We will not advise on a provisional rating at this time, but we are assured that all matters of concern within the Prevention of Future Deaths report have been fully assessed as described above.

Consideration of Criminal Investigation

On 1 April 2015 the CQC assumed enforcement responsibility for health and safety related serious incidents concerning people using services in health and social care settings in England.

In order to determine whether to commence a criminal investigation CQC apply the “Specific Incident Guidelines”.

Under this guidance, Inspectors, supported by Operations Managers, undertake an initial assessment of specific incidents to ascertain whether there is reasonable

suspicion that people using a regulated service have sustained avoidable harm or been exposed to a significant risk of avoidable harm.

Two questions are answered as part of the initial assessment.
1. Does the information about the specific incident raise concerns about ongoing risk of harm to users of the service which CQC should inspect?

2. Does the information about the specific incident suggest the harm sustained was avoidable and may have resulted from a registered person (Provider or Registered Manager) breach of a prosecutable fundamental standard? For example, a breach of Regulation 12(1) failure to provide safe care and treatment? If so, CQC should gather further evidence about the incident as part of a formal criminal investigation once that decision has been validated by CQC National Criminal Case Assessment and Progression Panel (CCAPP).

Our National Customer Service Centre team received a statutory notification of death from Mulberry Court Care Home on 30 January 2025. This notification did not proceed for further review as the details within the notification stated the death was expected and was part of an end-of-life care pathway.

In September 2025, CQC was notified of an inquest due into Mr Nelson’s death and requested information from the provider. This was to understand the actions taken in response to the incident and to assess whether there were any breaches of fundamental standards or regulatory requirements in line with our specific incident guidance.

CQC have taken steps to strengthen support for inspection teams to ensure the Specific Incident process is consistently followed in future cases in line with CQC’s Specific Incident guidelines. To enhance our oversight of Specific Incidents, we have established a Specific Incident Progression Team (SIPT). This team supports inspection staff in meeting our responsibilities for incident follow-up and ensures alignment with our enforcement powers.

The incident of Mr Nelson’s death was referred to SIPT on 28 November 2025. The team will consider the case to determine if it meets our regulatory threshold for enforcement action.

CQC are bound by a statutory limitation period. The statutory limitation period is set out in section 90(2) of the Health and Social Care Act 2008. It means we need to bring any prosecution both:

• within 12 months of when we have enough evidence that the case passes the test in the Code for Crown Prosecutors
• in any event within 3 years of when the offence was committed The latest date for limitation in this matter will be 26 January 2028.

I trust that the considered response provided, alongside the actions undertaken by the Care Quality Commission, offers the necessary assurance in accordance with

our regulatory responsibilities. We will continue to monitor the provider’s compliance with regulatory standards and ensure that learning from this case is embedded into practice. We remain committed to supporting improvements in patient safety and care quality across all services.

Dear Miss. Wood, REF: Response to Regulation 28 Report to Prevent Future Deaths Mr Ronald Colin Nelson (Deceased) On behalf of Mulberry Healthcare Ltd, I am writing in connection with the Regulation 28 report which was issued in connection with the death of Mr Ronald Nelson, who was resident of Mulberry Court Care Home (‘Mulberry Court/the Home’). I would like to express my deepest condolences to Mr Nelson’s family and friends. Introduction The Company and its staff strive to deliver the highest level of care to all residents. Prior to and during the course of the Inquest, the Registered Manager provided evidence to assist the Coroner’s enquiry and to explain the care and treatment provided to Mr Nelson, specifically with regard to protecting his skin integrity and providing appropriate pressure management. The Registered Manager provided and open and candid account and explained the changes that were implemented following Mr Nelsons’ death to further strengthen care recording and compliance with care plans. A Regulation 28 report was however issued on 15 January 2026, which raised concerns about poor record keeping and compliance with care plans. The Company has fully taken on board the concerns raised by the Coroner and is committed to taking any necessary steps to improve resident safety. The actions that were implemented following Mr Nelson’s death, and actions taken post inquest to address these issues are set out below. 61 DARNHALL CRESCENT ■ B1LBOROUGH • NOTTINGHAM ■ NG8 4QA TEL: 0115 929 4483
• EMAIL: INFO@MULBRRY COURTCAREHOME.COM ’

MULBERRY COURT CARE HOME IS A TRADING NAME OF MULBERRY COURT HEALTHCARE LIMITED COMPANY REGISTERED IN ENGLAND NO. 09612462

MULBERRY! COURT CARE HOME Notwithstanding the Company’s acceptance of the Coroner’s findings that there were omissions in care records and compliance with the care records, we have reviewed the Coroner’s judgement and make the following observations;
• Following Mr Nelsons’ first admission to NUH, Mr Nelson’s sacral area was not photographed by staff at NUHuntil 19.17 hours on 22 October 202 4, nearly an hour and half after he left Mulhrny Court. Attliis point therccords s tate that Mr Nelson had a Grade 2 pressure wound to theright butt ockand SDT I to the left buttock. A Grade 2 pressure wound and STDI can develop in under 1 hour in high-riskindividuals (which Mr Nelson was), particularly if no pressure area relief is given,tor example if he remained on a stretcher or trolley.
• We note that the Coroner found the Home’s notes contradictory and suggests that they were misleading. However, to clarify, thedescriptio ns of ‘redness’, ‘sore’ and ‘skin intact’ are all consistent statena nts to desribe skin that is not broken down. These descriptions are consistent with a Grade 1 pressure wound. A Grade 2 pressure wound is where the outer surface of the skin is damaged and the skin is broken down.
• Whilst in the care of NUH, it is recorded that on 25 October 2024, Mr Nelson developed a Grade 2 pressure wound of the left buttock and a Grade 2 pressure wound of the sacrum. These were new wounds that not recorded in NUH’s records when Mr Nelson was admitted to the Ward on 22 October 2024. The SDTI was described by staff at NUH as ‘evolving’.
• Mr Nelson was reviewed by his GP on 16 December 2024, who reported that the pressure area was improving, with some areas of healing on the edges, suggesting that the plan of care was appropriate.
• When Mr Nelson was admitted to NUH on 16 December 2024. , NUH’s records record that a skin assessment carried out on 17 December at 05.33am and recorded that the pressure wound was reviewed on admission and was Grade 3. A further review carried out on 17 December 2024 at 07.19am again confirmed the pressure wound to be Grade 3. When Mr Nelson was transferred to the ward at and reassessed at 22.41pm, the pressure wound was assessed and at this stage was Category 4.
• As acknowledged by the Coroner, Mr Nelson had a number of comorbidities which impacted on his skin integrity and the healing process, including poor nutritional intake, weight loss, urinary and faecal incontinence (which resulted in more frequent dressing changes, lessening their efficacy), and prescribed medication. 61 DARNHALL CRESCENT ' BILBOROUGH • NOTTINGHAM • NG8 -QA TEL: 0115 929 4433 ' EMAIL: INFO MULflERRYCOURTCAREHOME.COM
• WWW.MULRERRYCOURrCARfHOME.COM MULBERRY COURT CARE HOME IS A TRADING NAME OF MULBERRY COURT HEALTHCARE LIMITED COMPANY REGISTERED IN ENGLAND NO. 09612462

MULBERR C ARE H O M E COURT Action taken in response to the Regulation 28 Report: We have undertaken a review of the care delivery at Mulberry Court Care Home. This was independently led by a Manager from one of other services. Following this review, we prepared a service improvement plan (SIP). A copy of the SIP is attached at Annex A. The SIP was shared with both the CQC and ICB. All actions listed on the SIP have been completed. Dealing with the Coroner’s specific concerns we have taken the following action:
1. All staff were briefed regarding the Inquest and the Coroner’s findings and made aware of the concerns identified and informed of the action the Company was taking to address the Coroner’s concerns.
2. Every service user’s relative was contacted and provided with details of the Coroner’s findings and informed of the action the Company was taking to address the Coroner’s concerns. Families were offered the opportunity to for face-to-face meetings.
3. Clinical and medication competencies were carried out to ensure that staff were competent to run the shift.
4. We reviewed the Transfer to Hospital and provided further guidance to the staff about completion of the pack to ensure itcontains all relevant information for the resident.. The Transfer to Hospital pack ensures that the Hospital is provided with accurate information about a residents condition at the point of admission to hospital (including skin integrity and any concerns about skin breakdown). Compliance with the Transfer to Hospital pack is being reviewed on a weekly basis for a period of 6 months to ensure compliance.
5. We reviewed the Transfer Back Hospital pack to ensure it remains fit for purpose and Nurses have been trained on its use. Compliance with the Transfer back Hospital pack is being reviewed on a weekly basis for a period of 6 months to ensure compliance. Use of the Transfer Back from Hospital back is compulsory. The Pack requires;
a. Review of key documentation on return from hospital, including; body map, skin integrity check and documenting any areas of concern or skin breakdown, weight check, physical observations.
b. Review and upload of the discharge summary onto Nourish and copy sent to the Registered Manager (RM ) and Clinical Services Manager (CSM) for review. 61 DARNHALL CRESCENT • BlLBOROUGH • NOTTINGHAM ' NG8 4QA TEL: 0115 929 4483 ' EMAIL: 1NFO@MULBERRYCOURTCAREHOME.COM ’

MULBERRY COURT CARE HOME IS A TRADING NAME OF MULBERRr COURT HEALTHCARE LIMITED COMPANY REGISTERED IN ENGLAND NO 09612462

6. We reviewed the Wound Care Plans to ensure that they were fit for purpose, including the escalation process and that they were being used correctly and consistently by staff Staff have been instructed to ensure;
a. Each wound has an individual care plan and wound assessment in Nourish Care Planning system and wounds are not consolidated.
b. All wound photos have the measurements, date, name, body part, etc visible in the photo.
c. All wounds are documented on the wound tracker which is sent to the RM and CSM weekly for review and to ensure oversight.
d. All letters from the Tissue Viability Nurse (TVN) and dietician are uploaded into the correct care plan on the Nourish system. The care plan also details any instructions given by the TVN, including dressings & regime and any external health professionals to be contacted e.g., dieticians. e The TVN service has been informed that all instructions must be in writing and will not be accepted if given verbally.
f. A body map is completed for each individual wound or skin change on Nourish. Body maps are produced daily for all high-risk residents and are reviewed by Clinical Lead and Home Manager. Body maps are produced weekly for all residents and are reviewed by Clinical Lead and Home Manager.
7. We have reviewed communication process to ensure that staff are up to date with residents care requirements and changes in care need. We have reviewed our current processes to ensure that they are followed by staff. This includes;
a. A detailed handover is held at the start of each shift. This will be for all the care team allocated to that shift. The Nurse in Charge (NIC) will give a summary of the last 24 hours.
b. All residents are discussed at the handover. The NIC checks with all staff on shift before writing up the handover to ensure the information is reflective and up to date. This is in addition to the information recorded on the Nourish care planning system. 61 DARNHALL CRESCENT • B1LBOROUGH ■ NOTTINGHAM • NG8 €>A TEL: 0115 929 4483 ■ EMAIL: 1NFO@MULBERRYCOURTCAREHOME.COM ■ WWW.MULBERRYCOURTCAREHOME.COM MULBERRY COURT CARE HOME IS A TRADING NAME OF MULBERRY COURT HEALTHCARE LIMITED COMPANY REGISTERED IN ENGLAND NO 09612462

MULBERRY! CPU RT CARE H O M E
c. The handover template has been reviewed and redrafted. It includes;
i. High risk information
ii. AM / PM handover
iii. Supplementary Reviews
d. A daily huddle is undertaken in addition to the handover meeting at the start of the shift. All staff on shift are asked for an update on what they have noticed during their shift. Specific information includes; any skin changes, urine colour I odours, skin changes, residents not their usual self- etc. This is documented by the NIC or SCA every day at 10:30am & 15:30pm. Any concerns noted are to be checked by the NIC.
e. A daily meeting is carried out every day at 1 lam with the NIC of each floor, maintenance, catering, CSM, HR and the Home Manager.
f. All staff on shift are required to sign a “Read & Understood” document to state they are aware of what is currently being discussed in the daily meetings.
8. We have reviewed whether the current care planning systems is effective and have implemented a new auditing system to ensure that care plans are up to date, reflect residents’ needs, are understood by staff and are followed. This includes;
a. An effective care plan audit was devised for the home and staff trained on its use.
b. All care plans are evaluated effectively to reflect the information in the care plan has been reviewed. This is completed following any changes in presentation/need, or monthly as part of Resident of the Day
c. All residents care plans will be subject to full audit following readmission and then periodically.
d. All residents have a Resident of the Day completed every month. This is a full evaluation of the care plan and all risk assessments e The nursing team have regular clinical supervisions carried out and independently verified 61 DARNHALL CRESCENT ■ BlLBOROUGH ■ NOTTINGHAM • NG8 -QA TEL: 0115 929 4483 ’ EMAIL: 1NFO@MULBERRYCOURTCAREHOME.COM ■ WWW.MULBERRYCOtRTCAREHOME.COM MULBERRY COURT CARE HOME IS A TRADING NAME OF MULBERRY COURT HEALTHCARE LIMITED COMPANY REGISTERED IN ENGLAND NO. 1)9612462

MULBERR COURT C A F< E H O M E
9. We have reviewed how repositioning of residents is planned and recorded to ensure that it is person centred for the individual and addresses potential risk of harm. We have implemented further processes to make this more robust and ensure that there is appropriate oversight. This includes;
a. All repositioning times are set as an interaction on the individual timeline for the resident on the Nourish Care Planning system, setting out the intervals required between turns and the position.
b. All repositioning must be documented within the individuals care plan in the relevant sections, Skin Integrity, Wounds.
c. All care plans are evaluated to ensure that they effectively reflect the information in the care plan has been reviewed. This is completed following any changes or monthly as part of Resident of the Day evaluation.
d. The recording of repositioning and oversight has been strengthened has been addressed by staff utilising the full functionality of the Nourish Care Planning system. This is set out in more detail below.
10. We have a robust electronic care planning system that when staff use its full functionality it can effectively support staff to provide prompts to staff when care interventions are due, ensure that time critical care interventions are' met, and alerts are triggered to senior managers if any care intervention is missed. The system also provides the NIC and RM with effective oversight of care delivery staff utilise the full functionality of Nourish and that the system is used consistently in accordance with the Company procedures. This includes;
a. Each resident’s personalised interactions have been reviewed and set up on Nourish to ensure they are reflective of all their care needs.
b. Personalised prompts are set on the Nourish system to ensure that critical interventions are met.
c. For time critical interventions (for example repositioning) alarms are set to alert the NIC or RM if the intervention has not taken place.
d. The RM and CIM have oversight of the Nourish system to ensure that repositioning has been completed correctly and this is monitored throughout the day. 61 DARNHALL CRESCENT ■ BILBOROUGH • NOTTINGHAM ’ NG8 4QA TEL: 0115 929 4483
• EMAIL: INFO(*MULBERRYCOURTCAREHOME.COM '

MULBERRY COURT CARE HOME IS A TRADING NAME OF MULBERRY' COURT HEALTHCARE LIMITED COMPANY REGISTERED IN ENGLAND NO 09612462

MULBER RyfC OURT C ARE HO M E
e. Any paper documents that are required are evaluated and uploaded on to Nourish into the relevant section of the care plan.
f. A professionals / relatives log to be implemented on the electronic care plan
g. All information must be documented on Nourish. Any paper documents that are required are evaluated and uploaded on to Nourish. All staff have received training to support of the systems and process, including the Nourish care planning system to ensure that have the skills and competence to follow the Company’s procedures. Oversight is maintained through the Company’s oversight and governance policies. As stated above all actions have been completed. The Coroner raised concerns that issues may recur in the future. We wish to reassure the Coroner that the systems that have been put in place since Mr Nelson’s death are robust and the Company is fully committed to ensure that compliance is maintained. This has been verified by our external regulators. External Assurance We should also highlight that the CQC carried out an inspection on 17 and 18 February
2026. Whilst the final report is awaited we have received written feedback, and this is attached at Annex B. The CQC reported that they found no serious issues or concern within the service. With regard the specific areas of highlighted by the Coroner in her judgement, (assessment of risk continuity of care, assessing need and managing risk including pressure areas, and care recording) the CQC reported; lnvo/i>ingpeop/e to manage risks Risks were assessed and managed in line withpeople k needs, supported by training and monitoring systems. Alerts and reviews helped ensure interventions were delivered as planned, including positional changes. Safe systems, pathways and transitions Systems supported continuity of care and safe transitions, including timely referrals and information sharing with partners. Care plans were reviewed following hospital discharge and processes were in place to share information in the event of an emergency hospital admission. Assessing needs People k needs were assessed and reviewed using recognised tools, with detailed and personalised care plans. Additional guidance supported staff to manage key risks including nutrition and hydration and skin damage. 61 DARNHALL CRESCENT • B1LBOROUGH - NOTTINGHAM • NG8 4QA TEL: 0115 929 4483 • EMAIL: INFOtjiMULBERRYCOURTCAREHOME.COM ■ WWW.MULBERRYCOURTCAREHOME.COM MULBERRY COURT CARE HOME IS A TRADING NAME OF MULBERRY COURT HEALTHCARE LIMITED COMPANY REGISTERED IN ENGLAND NO 09612462

MULBER RAI COURT CARE HOME Delivering evidence-based care duel treatment Care was delivered in line with best practice, including pressure care and nutrition. Monitoring supported timely responses to changes in health including weight loss. Monitoring and improriw outcomes Outcomes were monitored to identify risks and drive improvement. Staff responded positively to professional guidance. Shared direction and culture Leaders promoted a clear vision and expectations. Staff understood their roles and responsibilities. I trust that this report demonstrates the Company and its staff have undertaken a detailed and robust review of systems and process to ensure that the issues the Coroner raised have been addressed and effective measures have been implemented to ensure that improved ways of working are sustained. In the meantime, should you require any further information, assistance or require discussing this matter further, then please don’t hesitate to contact me on YourssinceivTy? Director 61 DARN HALL CRESCENT • B1LBOROUGH • NOTTINGHAM • NG8 4)A TEL: 0115 929 4483 ’ EMAIL: INFO@MULBERRYCOURTCAREHOME.COM
• WWW.MULBERRYCOIRTCAREHOME.COM MULBERRY COURT CARE HOME IS A TRADING NAME OF MULBERRY COURT HEALTHCARE LIMITED COMPANY REGISTERED IN ENGLAND NO. 09612462