Dear Mr Myers, Response to the Regulation 28 report in the Marion Jones inquest write in response to your Prevention of Future Deaths report (PFD) issued on August 2025 following Mrs Jones's Inquest Your letter was addressed to Mr Andrew Knight; the Chief Executive Officer of Care UK, who asked me to carry out a thorough investigation before formally responding: ar a Solicitor qualified in 1996. joined Care UK in October 2007 to set-up the legal function and have run it since then. One of my responsibilities is the oversight of any Coroners' Inquests that Care UK is involved with_ At Care UK we take ay Prevention of Future Deaths report very seriously ad we appreciate the opportunity to look into the concerns outlined in your report. The investigation has involved Danielle Whittaker, the Home Manager of Riverside care home; Dave Ankers, the Regional Director who manages Danielle; Jo Crossland, the Head of Nursing, Care and Derentia; Phil Clarke; the Head of Health & Safety; James Frewin, Head of Regulatory Governance and Rachel Harvey; the Director of Care, Quality and governance who also manages Jo, Phil and James. We will address each of your concerns separately: Bed Rails You raised a concern regarding the lack of assessment for bed rails for Marion Jones in paragraphs 1,,2 and 3 of your report: "1. No pre-admission assessment for bed rails was recorded by the staff member responsible from Riverside, and this does not appear to have taken place. This is in circumstances where bed rails were already in place at Willow Wood and where there were obvious and recorded difficulties with regard to movement in and about bed, in addition to physical activity more generally: Care U< Care Services Limited Registered in England. Registration Numbe . 02571516 Registered otfice: Connaught House, 850 The Crescent Colchester Business Park; Colchester Esser CO4 90B We having

Given the circumstances, a pre-admission assessment for bed rails should have taken place and/ or been recorded: The inquest heard that family members raised their concerns on admission of Marion Jones to Riverside when they saw there were no bed rails were assured that an assessment would take place: This did not happen it should have done.
3. The manager of the care home agreed that in all the circumstances, including the concerns of the family, such an assessment should have taken place It is Care UK policy that where residents are assessed or present as at risk of falling out of bed, the use of bed rails should be considered: In Marion' $ case, the pre-admission assessment did not identify a risk of falling out of bed that would have triggered the bed rails assessment_ However, Marion had bed rails in her previous placement and upon admission her family raised concerns regarding bed rails. In those circumstances, Danielle agreed that a bed rail assessment should have taken place: In order to prevent this happening again in the future, we have made the following changes outlined below: Pre-admission assessment The Care UK pre-admission assessment proforma has been updated. This will ensure that colleagues assessing care needs for potential residents in any of our care homes are prompted to complete a bed rail assessment: These changes are the following: a) Under the 'Sleeping' section: We have included the information regarding any history of falls. A tick was added to indicate the use of any equipment at the time of the assessment: b) Under the 'Moving and Positioning' section: i) A phrase has been added 'for bed rails see Sleeping section' c) Before the Home Manager's signature, phrase has been added to clearly outline that the Home Manager confirms that the form has been filled out in full with no gaps, any reasons provided for any unavailable information, and that they believe that the care home can support the resident' s needs. These changes will our colleagues to consider a bed rails assessment on two occasions: when assessing sleeping needs and then moving and handling needs. Additionally, Managers will ensure completion of all the entries prior to signing the assessment: B. Admission check-list form Once the resident is admitted into our care, colleagues will complete a number of assessments in order to plan the care we will provide. These assessments are reviewed on a monthly basis or even sooner if there are any changes to their needs: Our admission checklist ensures that all the relevant assessments are completed post admission as it includes a list of the assessments and the timeframe for compliance. Previously, the checklist had prompt for the Multifactorial Falls Risk Assessment (MFRA) to be completed within 6 hours post admission: Now we have revised the prompts and improved the checklist to support colleagues completing the admission process in timely manner. These are the changes included in the new checklist: all initialisations have been expanded to include the full wording and the initialisation. This will provide clarity on which assessment must be completed. a new section has been added under the falls assessment to explain that a risk assessment must be completed to confirm if bed rails/fall out (crash) mat/sensor mats are required, and to consider any history of falls within 6 hours of admission: This inclusion will give our colleagues another opportunity to consider whether bed rails or fall out (crash) mats are required post admission. 2 They being box " guide Home

The layout of this document has also been re-formatted from portrait to landscape to allow for extra space; we have added tick boxes for 'ves' or 'no / N/A', and the form now states that further information must be provided if the 'no / N/A' is ticked. This improvement will allow further reflection as to why any measures have not been implemented whereas previously, thev did not need to provide further reasoning: The updated pre-admission assessment and admission checklist will be live on our intranet "mycareuk" from 7 October 2025 and an email from our internal communications platform "icommunicate" will be circulated with a link to these forms on the same day: Nurses' knowledge You also raised concerns that the nurses who gave evidence during the inquest lacked knowledge of the timing for completing the bed rails assessments in paragraphs 4, 5 and 6. "4. A registered general nurse involved in care for Marion Jones, and who found her after she had fallen, gave evidence that an assessment for bed rails should have taken place 48-72 hours after admission: The manager of the care home gave evidence that such an assessment should take place as promptly as possible, and that 48-72 hours did not meet this requirement: The nurse did not appear to appreciate the time within which such an assessment should be conducted: Another registered general nurse involved in the care of Marion Jones gave evidence that she was not sure in what period of time an assessment for bed rails should take place
6. Therefore, nursing staff responsible for the care of Marion Jones did not know what the appropriate approach was to assessment for bed rails. The awareness of nursing staff at Riverside with regard to assessment for and / or the requirement for bed rails was not apparent" As previously outlined, we have made changes to our pre-admission pro-forma and admission checklist that will ensure that colleagues consider bed rails assessments before and after admission: In addition to these changes, we are launching a Bed Rails eLearning module which will improve the knowledge of colleagues assessing residents in relation to our policies and procedures regarding bed rails assessments This eLearning module will be live on our e-learning platform 13 October 2025_ Also, we have amended our documentation on our "Go Audits" tool. These are audits completed on a monthly basis by our Deputy Home Managers. look at the individual assessments that form part of a resident's care plan, for example: MUST Assessment; MFRA Assessment, Choking Risk Assessment; etc. The Audit ensures that all necessary parts of a care plan have been completed, all necessary information has been included, and the information is up-to-date: We have now added an additional question that covers the completeness of the Admission Checklist within the required timeframes These amendments will go live this month and will allow management to audit compliance with the implemented changes. Finally; we have updated our Care & Clinical Meeting Notes form to include that checks should be made as per completed risk assessments, and that the admission checklist should be completed within the required timeframes 3 from They fully

Previous Incidents Your final concern was regarding evidence given during the inquest that there have been previous incidents where bed rails have not been in place. discussed this concern with the Home Manager and the Regional Director for Riverside care home. Danielle explained that during the inquest she gave evidence that previous incidents had occurred where bed rails were not in place However, she explained to me that she was referring to incidents where residents had rolled out of bed without bed rails in place, but a low-rise bed with a crash mat was in place in order to prevent injury: She has reassured me that she was not referring to any previous incident where a resident with no bed rails had fallen out of bed with no fall out (crash) mat According to Care UK's falls management and prevention policy high/low beds should be considered as an alternative to bed rails (6.4). These measures are considered a less restrictive option for residents at risk of falling out of bed. We are confident that we have implemented a robust series of improvements to our forms, training and audits which address the concerns that were raised during the Coroner' s inquest and set-out in the PFD. However, please do not hesitate to contact me should you have any queries.