_ The Court heard the home do not use pendant call alarms_ This was described as a business decision: The Home has 18 residents of mixed falls risk but less than half would be of a moderate or high risk of falls. The Court was concerned that for those residents a fixed call bell may not be of assistance, as in this case, as it would be out of reach when required: ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe each of you respectively have the power to take such action_ YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 10/07/2021. the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action_ Otherwise you must explain why no action is proposed. July

COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely: The family of Mrs Chiverall am also under a duty to send the Chief Coroner a copy of your response_ The Chief Coroner may publish either or both in a complete or redacted or summary from: He send a copY of this report to any person who he believes may find it usefulor of interest You may make representations to me the coroner at the time of your response, about the-telease or the publication of your response by the Chief Coroner Date: VLRA Signed (oaxtoxd may