Dear Johanna Thompson

Subject: Regulation 28: REPORT TO PREVENT FUTURE DEATHS

I am writing in relation to the Investigation and Inquest into the passing of Jean Groves, who sadly died on 24 March 2025, and the associated Regulation 28: Report to Prevent Future Deaths. I am the Registered Service Manager for the Swift Response Service, and I would like to express my sincere condolences on Jean’s passing.

The Swift Response Service works closely with the East of England Ambulance Service (EEAST), accepting non-injury falls and no-response alarm activations via their Access to the Stack (A2S) portal.

On the morning of 24 March 2025, access records indicate the Swift Response Service received a referral from EEAST to attend a no-response alarm activation for Jean. At 06:23, the on-duty manager accessed Jean’s Liquid Logic record (our Social Care reporting system) to review the information held, they would have specifically looked for access details, as these had not been provided by EEAST.

As no access details were recorded on the system, the referral was subsequently declined and returned to EEAST. If we have no access details recorded on the A2S referral portal or the Service Users Social Care record our process is to decline the referral and return to Stack. In accordance with our usual process, details of declined referrals should be recorded on the Service User’s Social Care record. Unfortunately, in this instance, no such record was created. This was an internal recording error; it had no impact on our decision making.

The manager on duty at the time does not remember the referral. He has confirmed that he is fully aware of the correct procedure, which requires the creation of a contact on the Service User’s record outlining the referral and the reason for its decline. He acknowledges that he did not follow this process on this occasion and has assured that he will adhere to it strictly going forward.

To prevent a recurrence of a recording error a communication is being issued to all Operational Managers and Reablement Liaison Officers responsible for triaging incoming referrals. This will remind staff that every referral—whether accepted or declined—must be recorded on the Service User’s Liquid Logic record, and that all attempts to obtain access details must also be clearly documented to ensure a complete and transparent audit trail.

If you require any further information, clarification, or documentation, please do not hesitate to contact me

Dear Ms Thompson Regulation 28 Report to Prevent Future Deaths – Jean Groves We write in response to your Regulation 28 Report dated 23rd January 2026 concerning the death of Ms Jean Groves. We offer our sincere condolences to Ms Groves’ family and are grateful for the opportunity to respond. We understand that the concern identified in the Report relates to the availability of property access details when cases are routed through community response pathways following escalation to emergency services. Careline365 operates an Alarm Receiving Centre (“ARC”) providing monitoring services for technology-enabled care alarms. Where appropriate, alarm activations are escalated to emergency services or other responders. Incident response At 04:53 on 24th March 2025, Ms Groves activated her pendant alarm, which connected to our ARC. The operator could hear that Ms Groves was distressed but was unable to determine clearly what had occurred or whether she had sustained an injury. As injury could not be ruled out, the operator appropriately escalated the incident to 999 at 04:54. During the emergency call, the operator informed the ambulance call handler that Ms Groves had apparently fallen and was believed still to be on the floor. The ambulance call handler was also informed that Ms Groves had learning difficulties and dementia. When specifically asked whether

Telephone: 0800 101 3333 | Email: info@careline.co.uk | Visit: www.careline.co.uk Registered Address: Oregon House, 19 Queensway, New Milton, England, BH25 5NN | VAT Reg: GB 325831310 Company Number: 09614529 any key safe or access details were available, the operator confirmed that no key safe was recorded on the account. The East of England Ambulance Service NHS Trust subsequently categorised and managed the call. Our ARC made further attempts to contact Ms Groves and later contacted the ambulance service to obtain an update while attendance was awaited. Access information Following receipt of the Regulation 28 Report, Careline365 reviewed its records and the referral documentation relating to Ms Groves’ telecare service. Ms Groves’ telecare account formed part of a portfolio of service users transferred to Careline365 from Saffron Housing Association during a bulk migration of monitoring services. The dataset transferred to Careline365 contained standard ARC account information, including personal details, medical information and emergency contacts where available. Subsequent review confirms that no key safe or property access details were included for Ms Groves in the migrated records and were therefore not recorded on her account. Our records show that no key safe or other property access details were recorded on Ms Groves’ account. The Norfolk County Council Assistive Technology referral documentation subsequently provided to Careline365 also recorded that no key safe was present at the property. Accordingly, when the ambulance service asked whether any key safe or access details were available, our operator accurately confirmed that none were held. It is not unusual for telecare users living in private dwellings not to have a keysafe or other formal access arrangement. Where such arrangements exist, we record them and communicate them to emergency responders when a call is escalated Careline 365 do not install or control property access arrangements unless specifically requested by the Service User or the referring authority, in this case Norfolk County Council. Where no access arrangements are recorded, the ARC escalates the incident to the emergency services and provides all available information. The emergency services then determine how to gain access. Careline 365 do not have visibility of the precise method by which the ambulance service ultimately gained access to the property which falls within the operational control of the attending ambulance crew. Referral pathway The working arrangements between the Assistive Technology team and community alarm providers are reflected in a Telecare Service Level Agreement describing partnership working arrangements for telecare sensors linked to alarm units. The document notes that these arrangements operate as partnership working rather than a formally commissioned service. The working arrangements between the AT team and community alarm providers are reflected in a Telecare Service Level Agreement which formalises partnership working arrangements for telecare sensors linked to alarm

Telephone: 0800 101 3333 | Email: info@careline.co.uk | Visit: www.careline.co.uk Registered Address: Oregon House, 19 Queensway, New Milton, England, BH25 5NN | VAT Reg: GB 325831310 Company Number: 09614529 units. The document records that these arrangements represent informal partnership working rather than a commissioned service. The Telecare referral form used within this pathway includes a field asking whether there is a key safe at the property but does not require that such arrangements exist. “Access to the Stack” pathway Careline365 does not operate or control the NHS “Access to the Stack” pathway. Our role was to respond to the alarm activation and escalate the incident to 999 due to the uncertainty regarding injury. The subsequent categorisation of the call and the decision to refer the case through the community response pathway were matters for the ambulance service. From the material subsequently disclosed to us during the inquest process, we understand that the Norfolk Swift Response Service declined the referral because injury could not be confirmed and no access details were recorded on their systems. Careline365 does not participate in, or have operational visibility of, the internal triage or dispatch decisions taken by ambulance or community response services once a call has been escalated. Review and organisational learning Although the evidence available does not indicate any delay or operational failing in the handling of this incident by our ARC, we have nonetheless reviewed our procedures to consider whether any further steps are appropriate. As part of this review we have:
• Confirmed procedures for recording and communicating property access information where it is provided;
• Reviewed onboarding and data capture processes to ensure appropriate prompts exist to record access arrangements where known; and
• Considered the wider issue of ensuring that access arrangements are appropriately recorded and communicated within multi-agency emergency response pathways. Careline365 is certified under the Technology Enabled Care Services Association (TSA) Quality Standards Framework (QSF), and our review did not identify any departure from the TEC Monitoring module standards in the handling of this incident. Conclusion We recognise the importance of ensuring that property access arrangements are clearly recorded and communicated within multi-agency emergency response pathways and remain willing to assist further should any additional information be helpful.

Telephone: 0800 101 3333 | Email: info@careline.co.uk | Visit: www.careline.co.uk Registered Address: Oregon House, 19 Queensway, New Milton, England, BH25 5NN | VAT Reg: GB 325831310 Company Number: 09614529