Dear HM Coroner, Re: Regulation 28 Report to Prevent Future Deaths Inquest touching the death of Pamela George (Deceased) Premiere Health Ltd acknowledges receipt of the Regulation 28 Report issued following the inquest into the death of Pamela George, concluded on 22 January 2026. Firstly, we wish to express our sincere condolences to Ms George’s family following their loss. Premiere Health Ltd and Cann House Care Home have carefully considered the matters identified in your report. While the organisation notes the narrative conclusion reached by the Court, we take the concerns raised seriously and have undertaken a comprehensive review of relevant policies, governance arrangements and operational practices at Cann House Care Home. Set out below is the organisation’s response to each matter of concern.

1. Systems for Actioning Hospital Discharge Summaries and Post-Discharge Blood Tests The Coroner raised concerns regarding the absence of regular blood testing following Ms George’s discharge and the lack of a clear system for ensuring discharge summaries were properly actioned. Following the inquest, the following actions have been implemented:
• All staff responsible for admissions have received one-to-one supervision regarding Ms George’s case, ensuring learning is embedded.
• Information has been disseminated to all junior staff for awareness training, emphasising the importance of correctly processing admission and discharge documentation.
• All hospital discharge summaries are now scanned directly into residents’ care plans upon receipt.
• The organisation has enforced its formal Hospital Discharge and Clinical Follow-Up Procedure, which includes:

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o Senior staff review of all discharge documentation within 24 hours. o Use of a Clinical Action Log to record and allocate required actions (e.g., blood tests, follow-ups). o Mandatory confirmation with GP surgeries within 48 hours regarding follow-up requirements. o Management oversight and audit of all discharged-related actions. These measures ensure transparency, accountability, and documented completion of all post-discharge clinical tasks.

2. Monitoring and Management of Infection The Coroner noted insufficient documentation regarding the progression of the resident’s breast infection between 25 May and 27 June 2023. The service has taken the following steps:
• Staff have received feedback on the importance of record keeping, particularly where care is refused.
• All staff will undertake refresher training on record keeping, including expectations for documenting infection progression.
• The Care Manager now conducts daily checks on notes for residents who may be declining personal care or presenting clinical concerns. o In the Care Manager’s absence, this is undertaken by the Team Leader.
• Registered Nurses are required to take action on concerns escalated to them and update care plans accordingly.
• Wound and Infection Monitoring Chart including documenting photographs is being used effectively to ensure clear, regular and structured documentation.
• A consolidated clinical escalation protocol is being implemented, requiring early medical review where symptoms do not improve.
• Staff training in infection recognition, wound documentation, sepsis awareness and escalation has been reinforced.

3. Escalation of Increasing Care Needs to Adult Social Care The Coroner identified concerns regarding whether Ms George’s needs exceeded those the home could safely meet, and whether appropriate escalation to Adult Social Care occurred. Actions taken include:
• Cann House Care Home has reviewed its acceptance criteria and will no longer accept residents requiring 1:1 support, recognising the significance of the challenges faced in Ms George’s case and wider systemic issues around funding.

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• All staff have been reminded of the importance of documenting and communicating concerns to Social Workers and Adult Social Care, both at admission and throughout residency.
• A requirement is in place for multidisciplinary reviews where needs increase significantly.
• A documented escalation procedure now mandates notification to the placing authority where needs may exceed home capability.
• All escalation discussions and communications with commissioning bodies are now formally recorded.

4. Documentation of Falls and Escalation for Medical Review The Coroner noted concerns regarding the clarity of documentation surrounding Ms George’s fall and post-incident clinical observations. In response:
• All staff have been reminded of the established incident procedure.
• A new system has been implemented whereby a manager reviews all incident forms immediately following any incident to ensure detail, completeness and clinical appropriateness.
• A strengthened Falls Management and Post-Incident Observation Procedures in place, including: o Comprehensive documentation of the fall circumstances. o Required physical observations and pain assessments. o Neurological observations where clinically indicated. o Clear documentation of clinical reasoning regarding escalation to medical professionals.
• Mandatory post-fall observation charts are now used for unwitnessed or potentially injurious falls.
• All care staff have received refresher training in incident reporting and falls management.

5. Documentation of Mental Capacity The Coroner identified that capacity assessments were not clearly documented. Actions implemented:
• All trained staff are completing further mental capacity and MCA training, delivered in-house or via Plymouth City Council.
• A formal Mental Capacity Assessment Procedure is now in place requiring:

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o Clear documentation where there is reason to believe a resident lacks capacity regarding a specific decision. o Recording of assessment outcomes in the care plan. o Documentation of best-interest processes where required.

6. Policies and Governance Arrangements The Coroner observed concern regarding the availability and sufficiency of policies, particularly in areas such as medication, escalation and reporting concerns. Actions taken:
• A full review and consolidation of all operational policies has been completed.
• Updated policies now in place cover: o medication management o infection control o incident reporting o clinical escalation o safeguarding o reporting concerns o hospital discharge management
• Policies are now centrally stored within a digital governance system, accessible to all staff.
• Regular audits are undertaken to ensure compliance.

Governance Oversight and Monitoring To ensure sustained improvement, Premier Health Ltd has strengthened governance oversight through:
• Routine clinical audits
• Management supervision and competency checks
• Monitoring of incident trends
• Senior management oversight visits These measures support continuous quality improvement and ensure the actions implemented remain effective and embedded.

Conclusion

Cann House Care Home Tamerton Foliot Plymouth PL5 4LE

Premiere Health Ltd acknowledges the matters raised within the Regulation 28 report and has undertaken a detailed review of the systems and processes in place at Cann House Care Home. The actions outlined above are intended to strengthen clinical oversight, documentation, escalation and governance across the home. We trust that this response assists the Court. Should the Coroner require any further information regarding the actions described above, Premier Health Ltd would be pleased to provide clarification.

Dear Mr Gittins

Prevent Future Death Report relating to Heather Louise Parkhill.

I am writing in response to the Regulation 28 report to prevent future deaths, that you issued on 2 February 2026 and wish to share again my sincere condolences with Mrs Parkhill’s family. “For many years, myself and other coroners have raised concerns regarding so called “ambulance delays” and I recognise that the challenges faced by WAST around the availability of resources are the result of multifactorial issues, however problems regarding the unavailability of resources persist. I have a mandatory statutory responsibility to raise concerns where they exist and it is clear that lives continue to be lost as a result of this problem. Despite all of the multi-agency efforts to improve the availability of resources and hence response times, nothing appears to change I therefore remain concerned that lives continue to be at risk.”

WAST response to your concerns The concern you express about the continued impact and harm resulting from extensive community waits for ambulances is shared by myself, the Executive team and our Trust Board at WAST. Over the years, the Trust has shared with you all the measures that have been taken in an attempt to manage and address the changes in the pressures both within the Trust and across the wider NHS Wales landscape. These actions include:
• Increasing our remote clinical support to ensure we are prioritising our available resources effectively based on the presenting needs of patients and also to improve safety netting when we are under significant pressures
• Minimise the number of patients being transported to already busy hospitals by enhancing staff knowledge, skills and competencies and the alternatives available to them
• Increase resources available for use, completing roster changes to increase resource availability and improving levels of attendance levels
• Offering more treatment at home, or away from the hospital environment in partnership with Health Board colleagues You correctly identify that current challenges are multi-factorial in cause and the Trust continues to work tirelessly with system partners to achieve the changes that our population deserves. Managing 999 ambulance demand In July 2025, a new emergency ambulance performance framework was introduced in Wales, supporting a move away from time-based targets towards a more clinically driven, outcome- focused approach, with an emphasis on responding quickly to people with time-sensitive conditions. Two new categories of call were initially introduced in July – a new purple category for people suffering a suspected cardiac and respiratory arrest and the red category for people at high risk of cardiac and respiratory arrest, including where this is a result of injury or illness. As part of the framework, all 999 calls to WAST, which are not classified as either purple or red, go through rapid clinical screening to ensure everyone receives a more tailored approach. This means the ambulance service takes account of their symptoms and where the incident occurred to determine what sort of response they receive. Every person receives a tailored response but not everyone will need an ambulance – they may receive a different clinical response, which is appropriate to their needs. An additional 28 clinical advisers – new posts – were recruited to support this new process to ensure people get the right response the first time. The next phase of the framework was introduced in December, following a clinical review of the amber and green categories of call. A new orange – time-sensitive response category was introduced. This was designed to ensure people with conditions such as suspected stroke or STEMI are identified earlier through enhanced clinical screening in the 999 contact centres to receive a faster, more appropriate ambulance response, and rapid transport to specialist care.

The new framework also increases opportunities to better understand patient outcomes and experience by broadening measurement beyond initial response times to include more clinically meaningful metrics, such as call-to-door times. The intent is to enable clearer insight into the timeliness and quality of care delivered to patients with serious and time-sensitive conditions, including stroke, to drive quality improvement. The changes are being tested for 12 months and will be thoroughly evaluated. I understand that Mrs Trish Gaskell, the Trust’s former Solicitor, had made the offer to you to attend the Clinical Contact Centre now located in St Asaph, to observe firsthand the changes that have been made to our response model. Improving ambulance patient handover performance All health boards are expected to deliver the Ambulance Patient Handover Guidance, published by the Welsh Government. This was updated in January 2026 and issued to health boards for immediate delivery. I enclose a copy of that guidance for your reference. This reinforces that ambulance patient handover is a whole system responsibility, requiring co-ordinated action across all parts of the NHS and aligned to existing escalation arrangements. It also expects a more consistent approach to monitoring, assurance, and accountability, enabling system leaders to identify and address the underlying causes of handover delays rather than managing the symptoms alone. Last year the Cabinet Secretary for Health and Social Care set up a clinically-led National Handover-45 Taskforce to support delivery of a recommendation made by the Ministerial Advisory Group on NHS Performance and Productivity to eliminate ambulance patient handover delays of more than 45 minutes. The taskforce has brought together senior clinical, operational and system leaders from across NHS Wales and has overseen focused improvement activity, shared good practice, and provided national clinical leadership on safe and timely handover. Its work has helped to strengthen understanding about why handover delays happen, reinforced the importance of whole-system flow, and supported measurable improvements in handover performance across a majority of hospital sites in Wales. I enclose a copy of the Ambulance Handover Accelerated Design Events Integrated Thematic Summary, which provides more detail and context regarding the National Handover-45 work. I appreciate that these broad system-based actions will not diminish the loss experienced by Mrs. Parkhill’s family. I am genuinely sorry that we were not able to deliver the service I am committed to offering to them. If you wish to take up the offer of visiting our clinical contact centre (now based at St Asaph) please contact , Legal Services Manager, who will be happy to arrange this. I understand that the Trust’s Executive Director of Nursing, has also offered to meet with you recently, and this can also be arranged via