Dear Ms. Benyounes,

We write further to the Regulation 28 Report issued on 9 October 2025, following the Inquest touching the death of Mrs. Pauline Stirling. We extend our deepest sympathies to the family of Mrs. Stirling, who was a much-loved resident of Covent House Care Home (the “Home”).

Mrs. Stirling sadly died on 7 March 2024, with the medical cause of death being Bronchopneumonia, chronic osteomyelitis secondary to pressure sores, with contributing conditions of Alzheimer’s Disease and Lewy Body Dementia. During the Inquest, the Court heard evidence about the measures Malhotra Care Homes Limited (the “Company”) have implemented since Mrs. Stirling’s residency at the Home circa two years ago. We acknowledge the Court’s concerns that further work from that time would be required, particularly in relation to pressure damage prevention, and we welcome the opportunity to provide assurance that significant improvements have been made and continue to be embedded across the Company.

We have addressed each of your matters of concern in detail below, and have provided a bundle of supporting documentation.

1. To date, the documentation for recording positional changes only requires care staff to input the position right, left, back, in chair with no reference to positional tilt to avoid pressure damage.

As referenced during the Inquest, the Home transitioned to an electronic care recording system, Nourish, in May 2024. We acknowledge that this is a fairly new system, and that prior to the Inquest, there was no ability to input a positional tilt in the positional changes screen of Nourish. Immediately following the Inquest, we added a 30-degree tilt interaction, named a ‘hip tilt’, which is evidenced in our supporting documentation bundle (Exhibit 1).

Registered Office: Malhotra House, Malhotra Group PLC, 50 Grey Street, Newcastle upon Tyne, NE1 6AE Tel: 0191 233 0387 Fax:0191 260 2342 Email: reception@malhotragroup.co.uk Web: www.malhotragroup.co.uk Malhotra Group PLC (7918146) & Subsidiary Companies. VAT Reg. No. 175 4446 89 The 30-degree tilt reflects the ’30 Degree Tilt – to support pressure relief’ leaflet, provided by the Tissue Viability Service, a copy of which is supplied in the supporting documentation bundle (Exhibit 2). This provides that a 30-degree tilt allows care givers to reduce pressure relief for individuals who are unable to self-reposition in bed by reducing direct pressure to the larger bones of the lower back, tail bone, buttocks and hips. By now adding this in, it allows greater transparency of the positional changes being made to any resident.

2. Whilst evidence was provided about the training requirements for full time members of nursing and care staff, to include mandatory full induction and refresher training, I am concerned having heard evidence that to adhere to the ratio of 2 RGNs per shift, agency nurses were regularly utilised, and no evidence about training requirements was provided.

The Company has taken steps to reduce its reliance on agency staff. This is demonstrated by an 11.95% decrease in expenditure on agency staff between February 2024, when Mrs. Stirling was a resident in the Home, and October 2025. This reduction has been achieved despite the inflation in wages that have occurred throughout this time period, including the effect of two national minimum wage reviews. In real terms, this would equate to an additional 11-15%. Where agency nurses are needing to be engaged, the Company requires the agency to provide evidence of mandatory training compliance, ensuring that our agency colleagues meet and maintain the professional standards expected from our own employees prior to their arrival a the Home, so to allow the home manager to assess the same.

3. Despite safeguarding referrals made due to concerns about wound management, and the issue of wound care, incorrect classification of pressure damage, and absence of expected documentation being raised initially by tissue viability nurses in January 2024, there is no evidence before the Court of training having been undertaken, including training offered by tissue viability nurses. The only training carried out was online webinar training by a former member of staff in March 2024.

This has been taken on board by the Company, and we can confirm that staff at the Home have been booked onto training provided by , Senior Tissue Viability Specialist Nurse for the Gateshead Health NHS Foundation Trust. This training will cover pressure ulcers and wound management and is booked for 16 and 17 December 2025. We attach a copy of the confirmation of this booking (Exhibit 3). Furthermore, we have sourced and delivered additional wound management training across the Company from an external company called ‘Caring for Care’. This is ongoing training, with further training sessions booked for 2026, and has been carried out by staff including Home Managers, Deputy Home

Registered Office: Malhotra House, Malhotra Group PLC, 50 Grey Street, Newcastle upon Tyne, NE1 6AE Tel: 0191 233 0387 Fax:0191 260 2342 Email: reception@malhotragroup.co.uk Web: www.malhotragroup.co.uk Malhotra Group PLC (7918146) & Subsidiary Companies. VAT Reg. No. 175 4446 89 Managers, Nurses, Senior Care Assistants and Care Assistants. Online training is also shared with the homes across the group, with staff encouraged to attend, including Online Tissue Society training and E-learning training for Healthcare.

Internally, managers meetings have included reflective sessions from Nursing Standards News, the management of skin tears has been shared with all home managers and nurses and minuted wound-care specific meetings and supervisions have been carried out with all home managers.

The Company is committed to embedding a proactive and preventative approach to wound care, ensuring that our staff receive appropriate and ongoing training. Our Training & Development Policy Statement, which echoes these sentiments, is reviewed annually at a minimum.

4. There were candid acceptances that documentation was not completed to an accepted standard and there were gaps in the records. This is not the first inquest where acceptances were made, therefore I remain concerned that this is an ongoing issue despite evidence that this has been addressed with an auditing system

We have made significant efforts to improve our ways of proactively preventing the potential for gaps in documentation. Since moving to a digital platform and changing the system as needed, we are now able to clearly identify when records have not been completed within the agreed-upon timeframe, as Nourish will automatically generates an alerts should this occur. This is evidenced in the supporting documentation bundle. The first screenshot (Exhibit
4) illustrates an example of a resident’s timeline. This timeline captures the resident’s daily needs and any required tasks that must be completed each day, which are tailored to the resident’s individual requirements and preferences. It focuses on scheduled care, such as mealtimes, personal care, clinical interventions, positional changes and assessments. The second screenshot (Exhibit 5) highlights the alert function under the ‘warnings’ header in the rask bar and on the ‘alarm bell’ in the top right corner. When a time-sensitive interaction is due, the system will trigger an alert if it has not been completed within 15 minutes, and again at 30 minutes. An ‘amber bell’ is escalated to nursing staff and a high-level ‘red warning’ is escalated to the Care Home Manager. This provides an additional safeguard to ensure that care is delivered when schedules, and that residents’ needs are met consistently and promptly. Please note that the screenshots in the bundle are from the training mode of Nourish, and therefore do not represent the needs of an actual resident due to Data Protection purposes. Therefore, the number of alerts visible on the right hand side of the first screenshot would not be reflective of an operational home.

Registered Office: Malhotra House, Malhotra Group PLC, 50 Grey Street, Newcastle upon Tyne, NE1 6AE Tel: 0191 233 0387 Fax:0191 260 2342 Email: reception@malhotragroup.co.uk Web: www.malhotragroup.co.uk Malhotra Group PLC (7918146) & Subsidiary Companies. VAT Reg. No. 175 4446 89

Nourish provides a ‘Wound Management View’, upon which care givers can see everything relevant to the wound in one place. Nourish proves a complete history of care with interactions recorded in the past and scheduled in the future to manage a wound or skin concern. When a new wound is recorded, the system will bring up different assessments, tailored to that specific wound type such as pressure damage, skin tears and moisture lesions. Within the ‘Initial Assessment’, care givers will be required to describe the wound in detail, upload a photograph and define a treatment plan. Wounds and body maps can also be linked to the resident’s care plan. A copy of the Nourish training guide on wound management is included in the bundle of supporting documentation (Exhibit 6).

The implementation of Nourish has significantly strengthened our oversight of wound manacomplete gement. Through the Nourish dashboard, the Home Manager can monitor and review all wounds within the care home, ensuring that any concerns are addressed promptly. At an organisational level, the Operations Team has a satellite view across all care homes within the Company, with each care home having its own dedicated Operations Manager to provide targeted oversight and guidance. Additionally, our Director of Care is holding fortnightly meetings to discuss wounds and the management of wounds within all care homes, ensuring consistent standards, shared learning and continuous improvement in the management of wounds.

We hope that this response, outlining the steps we have taken since the Inquest, and over the past two years since Mrs. Stirling’s residency within the Home, provides you with confidence that we have taken the Court’s concerns seriously. We recognise that the prevention of future deaths is not achieved through isolated measures but through sustained vigilance and continuous improvement. As a Company, we are committed to ensuring that the measures taken lead to lasting improvements, not only within Covent House but across our wider organisation.