Beatrice Smith
PFD Report
All Responded
Ref: 2025-0493
All 1 response received
· Deadline: 28 Nov 2025
Coroner's Concerns (AI summary)
No effective internal investigation was conducted after the death, missing learning opportunities. Staff also received no additional training or guidance, risking a repeat of inadequate practices.
View full coroner's concerns
(1) A safeguarding referral was made in respect of Mrs Smith's condition at the time. Despite this, and despite Mrs Smith's death, no effective internal investigation appears to have been conducted. I am concerned that the absence of such an investigation means that opportunities for learning are likely to be overlooked. In turn this risks residents being exposed to repeated practices that are inadequate. This is a risk to those residents.
2) I asked the Manager of Riverside Court whether any additional training or guidance had been provided to staff in the light of this incident and Mrs Smith's death. She replied that it had not. Given my concerns that Mrs Smith's condition was not well managed I am concerned that the absence of such training and guidance risks a repeat of these events.
2) I asked the Manager of Riverside Court whether any additional training or guidance had been provided to staff in the light of this incident and Mrs Smith's death. She replied that it had not. Given my concerns that Mrs Smith's condition was not well managed I am concerned that the absence of such training and guidance risks a repeat of these events.
Responses
Action Taken
Harbour Healthcare completed a Serious Untoward Incident Root Cause Analysis, reviewed and updated several policies and procedures related to safeguarding, wound care, infection control, sepsis awareness, and person-centered care and introduced a Coroners Learning Forum to share outcomes from Coroners Courts and serious incidents. The homes will also transition to electronic care plans in Jan 2026. (AI summary)
Harbour Healthcare completed a Serious Untoward Incident Root Cause Analysis, reviewed and updated several policies and procedures related to safeguarding, wound care, infection control, sepsis awareness, and person-centered care and introduced a Coroners Learning Forum to share outcomes from Coroners Courts and serious incidents. The homes will also transition to electronic care plans in Jan 2026. (AI summary)
View full response
Dear Mr Fleming. Re: Death Of Beatrice Smith, Riverside Care Home, Regulation 28 Response (Case Ref
15013096) I refer to your letter dated 6th October 2025 in relation to the above, please find below our response and actions in relation to this matter Harbour Healthcare Riverside Court Care Home Maryport Cumbria Regulation 28 Report to Prevent Future Deaths Response to Coroners Concerns into the Death of Mrs Beatrice Smith who passed away on 23rd April 2025 in West Cumberland Hospital following residing at Riverside Court Care Home Maryport Background Harbour Healthcare is a family run car provider established in 2012. Riverside Court Care Home was run by FSHC until it was one of a group of 19 homes as part of an acquisition to Harbour Healthcare on Friday 25th April 2025 Riverside Court is a 59 bedded Care Home with 2 communities over 2 floors offering care for individuals with nursing and residential needs and of those living with dementia and associated challenges. Our philosophy is quite simple, and we strive to provide an excellent standard of care to our residents treating them with complete dignity and respect.
Circumstances of the Death Mrs Smith was seen by her daughter and by an ACP from Cumbria Health on call on 17th April 2025. They both had significant concerns about Mrs Smith’s condition, and the ACP made a safeguarding referral. Coroners Conclusion Medical Cause of Death 1a Multiple Organ Failure 1b Sepsis 1c Infected Heel Ulcer Response Following the inquest a Serious Untoward Incident Root Cause Analysis was completed by Harbour Healthcare Head of Safeguarding with support from Human Resources. At the time of the incident Riverside Court was under FSHC policies and processes. If the incident had been investigated in line with our current policy and process this could have been shared as part of the inquest but as there was no evidence, we need to accept failure in process, however we are confident our updated process would give confidence that this process would be followed for any future incidents within the company. We have reviewed processes in the Home and coaching and support in key areas has been offered to the team along with refresher of training in Adults and Safeguarding and Wound Care. To validate learning competency and understanding this is done through reflective practice, and discussions at Stand-Up meetings, clinical meetings, supervisions etc. We have a Audit system in place along with an incident management system linked to a Risk Register so we have oversight as a company on key areas for monitoring and review of quality of care. Response As part of the internal Serious Untoward Incident RCA an action plan and lessons learned identified key areas of learning. There has been ongoing refresher training to all team members to support their understanding of Safeguarding of Residents Aswell as the eLearning on our ‘Your Hippo’ Training Platform related to wounds and skin there has been, and further training attended and planned with the NHS Tissue Viability Team on wound care for all team members offering direct care.
The Quality Team support the home with Observational Support Visits which look at the quality-of-care planning and wound management. There is ongoing themed supervisions and coaching to key team members to suppor5t ongoing development When the nurses are completing their wound care training, they are completing reflective practice accounts to validate learning. As a company we have implemented a Coroners Lessons Learned forum which are held via teams every month. These commenced in October and offer a presentation of a coroner’s inquest relating to a home and then the associated lessons learned The polices related to key areas have been shared with the team. Actions Taken
1. A Serious Untoward Incident Root Cause Analysis was completed by the Head of Safeguarding into the events from 15th April with a focus on 17th April 2025 supported by the Human Resources Business Partner (HRBP)
2. A Review of Wounds and skin risk in the Home was completed and Audited using our Viclarity System by the Registered Manager
3. A weekly wound monitoring form is then completed and updated and shared to the Operations Director, Regional Manager, Head of Safeguarding and Director of Quality for oversight and governance.
4. All team members have undertaken the Adults with Safeguarding E Learning Module to allow for refresher in this area
5. Impact and understanding of learning is being validated through reflective discussions at stand-up meetings, support visits and supervisions.
6. Riverside Court nurses have attended a wound care update by the local NHS trust and all team members who deliver care are signed up for further training and development through them early in 2026.
7. A camera is in place now to support taking regular pictures in line with guidance
8. Observational Support Visits were commenced which focused on key areas in including wound management and triangulation of care, and the team’s knowledge around safeguarding, recognising change, communication and associated actions.
9. The Registered Manager is carrying out further development and learning to the team through supervision and coaching which is being supported by the quality team for effectiveness.
10. There is a Governance Process in Place since June 2025 for all new Serious Untoward Incidents and we have a tracker monitored and reviewed by the Quality Team and Head of Safeguarding to look at detail in the RCA for lessons learned, actions, and trends in key areas
11. When completing the home add any actions to their Service Improvement Plan and share learning through their Clinical Governance Meeting
12. Shared learning and updates are reinforced through the Stand-Up Meetings each day in the Care Home along with Huddles for improvements in more effective communication.
13. Riverside Court is on the focus call group which is a process by Harbour Healthcare as part of the risk register where higher risks home due to key issues are invited to a call every fortnight with key team members to review he Service Improvement Plan, check progress and offer support if needed to meet any urgent or high risk actions.
14. Our VI clarity Audit and Monitoring System captures risk through the key care indicators report each month. This then feeds into our corporate Risk Register for allowing effective response to the homes for resident safety.
15. Harbour Healthcare have introduced a Coroners Learning Forum in October 2025 where a team’s call is open to all interested individuals to share outcomes from Coroners Courts or potentially serious incidents along with any associated lessons learned for the wider organisation. The outcome of Riverside Courts inquest was cascaded to the company on Wednesday 3rd November 2025
16. These lessons learned are evidenced through the clinical governance meeting and stand-up meetings.
17. All Homes who transitioned to Harbour Healthcare in April 2025 are being transferred to Electronic Care Plans (PCS) commencing Jan 2026 to allow for continued improvements in governance and monitoring. All of the above measures are underpinned by the following Policies and Procedures Safeguarding Adults Policy and Procedure – Reviewed 29th Oct 2025 CPN16 Wound, Bruise and Skin Conditions Policy and Procedure Reviewed 23rd Sept 25 CCN30 -Pressure Ulcer Management Policy and Procedure Reviewed 5th Nov 25 CC18 -Infection Control Policy and Procedure – Reviewed 25th June 25 CCN12 – Sepsis Awareness Policy and Procedure – Reviewed 20th Aug 25 CP11 – Person Centred Care and Support Planning Policy and Procedure – Reviewed 7th Nov 25 ABN11 – Root Cause Analysis Policy and Procedure Reviewed 16th Sept 25 Evidence Appendix (Available if required) Appendix 1 – Serious Untoward Incident Root Cause Analysis Appendix 2 – Weekly Wound Tracker Appendix 3 – Observational Visits Appendix 4 – Presentation and Lessons Learned from Forum Appendix 5 – Training Records Appendix 6 -Viclarity Audits for Wounds Appendix 7 – Viclarity Audit for KCI and Risk Monitoring Appendix 8 – Clinical Meetings/Stand up meeting templates Appendix 9 – themed supervision/coaching Appendix 10 – Associated Record of Discussions Should you require any further information please do not hesitate to contact me.
15013096) I refer to your letter dated 6th October 2025 in relation to the above, please find below our response and actions in relation to this matter Harbour Healthcare Riverside Court Care Home Maryport Cumbria Regulation 28 Report to Prevent Future Deaths Response to Coroners Concerns into the Death of Mrs Beatrice Smith who passed away on 23rd April 2025 in West Cumberland Hospital following residing at Riverside Court Care Home Maryport Background Harbour Healthcare is a family run car provider established in 2012. Riverside Court Care Home was run by FSHC until it was one of a group of 19 homes as part of an acquisition to Harbour Healthcare on Friday 25th April 2025 Riverside Court is a 59 bedded Care Home with 2 communities over 2 floors offering care for individuals with nursing and residential needs and of those living with dementia and associated challenges. Our philosophy is quite simple, and we strive to provide an excellent standard of care to our residents treating them with complete dignity and respect.
Circumstances of the Death Mrs Smith was seen by her daughter and by an ACP from Cumbria Health on call on 17th April 2025. They both had significant concerns about Mrs Smith’s condition, and the ACP made a safeguarding referral. Coroners Conclusion Medical Cause of Death 1a Multiple Organ Failure 1b Sepsis 1c Infected Heel Ulcer Response Following the inquest a Serious Untoward Incident Root Cause Analysis was completed by Harbour Healthcare Head of Safeguarding with support from Human Resources. At the time of the incident Riverside Court was under FSHC policies and processes. If the incident had been investigated in line with our current policy and process this could have been shared as part of the inquest but as there was no evidence, we need to accept failure in process, however we are confident our updated process would give confidence that this process would be followed for any future incidents within the company. We have reviewed processes in the Home and coaching and support in key areas has been offered to the team along with refresher of training in Adults and Safeguarding and Wound Care. To validate learning competency and understanding this is done through reflective practice, and discussions at Stand-Up meetings, clinical meetings, supervisions etc. We have a Audit system in place along with an incident management system linked to a Risk Register so we have oversight as a company on key areas for monitoring and review of quality of care. Response As part of the internal Serious Untoward Incident RCA an action plan and lessons learned identified key areas of learning. There has been ongoing refresher training to all team members to support their understanding of Safeguarding of Residents Aswell as the eLearning on our ‘Your Hippo’ Training Platform related to wounds and skin there has been, and further training attended and planned with the NHS Tissue Viability Team on wound care for all team members offering direct care.
The Quality Team support the home with Observational Support Visits which look at the quality-of-care planning and wound management. There is ongoing themed supervisions and coaching to key team members to suppor5t ongoing development When the nurses are completing their wound care training, they are completing reflective practice accounts to validate learning. As a company we have implemented a Coroners Lessons Learned forum which are held via teams every month. These commenced in October and offer a presentation of a coroner’s inquest relating to a home and then the associated lessons learned The polices related to key areas have been shared with the team. Actions Taken
1. A Serious Untoward Incident Root Cause Analysis was completed by the Head of Safeguarding into the events from 15th April with a focus on 17th April 2025 supported by the Human Resources Business Partner (HRBP)
2. A Review of Wounds and skin risk in the Home was completed and Audited using our Viclarity System by the Registered Manager
3. A weekly wound monitoring form is then completed and updated and shared to the Operations Director, Regional Manager, Head of Safeguarding and Director of Quality for oversight and governance.
4. All team members have undertaken the Adults with Safeguarding E Learning Module to allow for refresher in this area
5. Impact and understanding of learning is being validated through reflective discussions at stand-up meetings, support visits and supervisions.
6. Riverside Court nurses have attended a wound care update by the local NHS trust and all team members who deliver care are signed up for further training and development through them early in 2026.
7. A camera is in place now to support taking regular pictures in line with guidance
8. Observational Support Visits were commenced which focused on key areas in including wound management and triangulation of care, and the team’s knowledge around safeguarding, recognising change, communication and associated actions.
9. The Registered Manager is carrying out further development and learning to the team through supervision and coaching which is being supported by the quality team for effectiveness.
10. There is a Governance Process in Place since June 2025 for all new Serious Untoward Incidents and we have a tracker monitored and reviewed by the Quality Team and Head of Safeguarding to look at detail in the RCA for lessons learned, actions, and trends in key areas
11. When completing the home add any actions to their Service Improvement Plan and share learning through their Clinical Governance Meeting
12. Shared learning and updates are reinforced through the Stand-Up Meetings each day in the Care Home along with Huddles for improvements in more effective communication.
13. Riverside Court is on the focus call group which is a process by Harbour Healthcare as part of the risk register where higher risks home due to key issues are invited to a call every fortnight with key team members to review he Service Improvement Plan, check progress and offer support if needed to meet any urgent or high risk actions.
14. Our VI clarity Audit and Monitoring System captures risk through the key care indicators report each month. This then feeds into our corporate Risk Register for allowing effective response to the homes for resident safety.
15. Harbour Healthcare have introduced a Coroners Learning Forum in October 2025 where a team’s call is open to all interested individuals to share outcomes from Coroners Courts or potentially serious incidents along with any associated lessons learned for the wider organisation. The outcome of Riverside Courts inquest was cascaded to the company on Wednesday 3rd November 2025
16. These lessons learned are evidenced through the clinical governance meeting and stand-up meetings.
17. All Homes who transitioned to Harbour Healthcare in April 2025 are being transferred to Electronic Care Plans (PCS) commencing Jan 2026 to allow for continued improvements in governance and monitoring. All of the above measures are underpinned by the following Policies and Procedures Safeguarding Adults Policy and Procedure – Reviewed 29th Oct 2025 CPN16 Wound, Bruise and Skin Conditions Policy and Procedure Reviewed 23rd Sept 25 CCN30 -Pressure Ulcer Management Policy and Procedure Reviewed 5th Nov 25 CC18 -Infection Control Policy and Procedure – Reviewed 25th June 25 CCN12 – Sepsis Awareness Policy and Procedure – Reviewed 20th Aug 25 CP11 – Person Centred Care and Support Planning Policy and Procedure – Reviewed 7th Nov 25 ABN11 – Root Cause Analysis Policy and Procedure Reviewed 16th Sept 25 Evidence Appendix (Available if required) Appendix 1 – Serious Untoward Incident Root Cause Analysis Appendix 2 – Weekly Wound Tracker Appendix 3 – Observational Visits Appendix 4 – Presentation and Lessons Learned from Forum Appendix 5 – Training Records Appendix 6 -Viclarity Audits for Wounds Appendix 7 – Viclarity Audit for KCI and Risk Monitoring Appendix 8 – Clinical Meetings/Stand up meeting templates Appendix 9 – themed supervision/coaching Appendix 10 – Associated Record of Discussions Should you require any further information please do not hesitate to contact me.
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56-Day Deadline
28 Nov 2025
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 1 May 2025 I commenced an investigation into the death of Beatrice SMITH. The investigation concluded at the end of the inquest . The conclusion of the inquest was a narrative in the following terms:
Beatrice Smith was 88 years old. On 22nd September 2024 Mrs Smith was admitted to the Cumberland Infirmary, Carlisle, following a fall and long lie. Mrs Smith had a serious ulcer on her left leg. Whilst in hospital there was a period of one month during which Mrs Smith's ulcer was not seen or treated by Tissue Viability Nurses. Following their involvement, Mrs Smith's condition began to improve, but she had developed further ulcers including to her right heel. Mrs Smith was discharged to Riverside Court Care Home on 13th February 2025. Whilst resident there Mrs Smith's condition deteriorated seriously and the ulcer on her right heel became badly infected. Mrs Smith's condition noticeably worsened from 15th April onwards. Despite this, Riverside Court did not seek specialist attention for her and the ulcer was not always properly dressed. Mrs Smith developed sepsis. She was admitted to the West Cumberland Hospital, Whitehaven on 23rd April 2025. She died there at 17:01 on that day. Neglect, being the failure to seek specialist care and wound management for Mrs Smith following her deterioration on 15th April 2025, contributed to her death. I concluded that the medical cause of Mrs Smith's death was: 1a Multiple Organ Failure 1b Sepsis 1c Infected Heel Ulcer II Diabetes Mellitus, Dementia, Frailty
Beatrice Smith was 88 years old. On 22nd September 2024 Mrs Smith was admitted to the Cumberland Infirmary, Carlisle, following a fall and long lie. Mrs Smith had a serious ulcer on her left leg. Whilst in hospital there was a period of one month during which Mrs Smith's ulcer was not seen or treated by Tissue Viability Nurses. Following their involvement, Mrs Smith's condition began to improve, but she had developed further ulcers including to her right heel. Mrs Smith was discharged to Riverside Court Care Home on 13th February 2025. Whilst resident there Mrs Smith's condition deteriorated seriously and the ulcer on her right heel became badly infected. Mrs Smith's condition noticeably worsened from 15th April onwards. Despite this, Riverside Court did not seek specialist attention for her and the ulcer was not always properly dressed. Mrs Smith developed sepsis. She was admitted to the West Cumberland Hospital, Whitehaven on 23rd April 2025. She died there at 17:01 on that day. Neglect, being the failure to seek specialist care and wound management for Mrs Smith following her deterioration on 15th April 2025, contributed to her death. I concluded that the medical cause of Mrs Smith's death was: 1a Multiple Organ Failure 1b Sepsis 1c Infected Heel Ulcer II Diabetes Mellitus, Dementia, Frailty
Circumstances of the Death
Mrs Smith was seen by her daughter and by an ACP from Cumbria Health on Call on 17th April 2025. They both had significant concerns about Mrs Smith's condition and the ACP made a safeguarding referral. The ACP's note (which she wrote at the time) was as follows: "sat in chair on arrival. evident leaking haemaserous fluid from the right foot/ankle this was leaking underneath her sensor mat with noted blood clots on the floor from the exudate....I was very shocked at how Beatrice was sat with her leg wound pooling out in her room under her sensor mat. Daughter has raised concerns that this was how it was when she arrived yesterday". The Manager of Riverside Court attended the inquest and gave evidence. I asked her how Mrs Smith had been allowed to develop such a poor condition. She responded that she had attempted to find this out but had not been able to. She confirmed that she would have expected staff to conduct rounds and that they should have addressed Mrs Smith's deteriorating condition. She was not able to tell me why this had not occurred. I understand that Harbour Healthcare Limited is now the owner of Riverside Court.
Copies Sent To
in the inquest. the Care Quality Commission
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.