Dear Ms Godfrey, I am writing in response to the above Regulation 28 Report to Prevent Future Deaths, where you have asked the TEC Services Association C.I.C. (TSA) to provide details of action taken, or proposed to be taken, following the sad death of

About the TSA TSA is the industry body that works to drive the transformation of the TEC sector through strengthening Partnerships, Data and People, whilst recognising and responding to demand, scope and opportunities in Technology Enabled Care.

We endeavour to ensure the Quality and safety of Technology Enabled Care (TEC) by setting and developing standards and providing independent and trusted audit and certification, which is managed by our wholly owned subsidiary company, TEC Quality Ltd, a United Kingdom Accreditation Service (UKAS) accredited certification body.

We provide support and knowledge-share to members looking to improve the delivery of TEC services, grow their business or strengthen their impact on the TEC sector.

TEC Quality: Provide a UKAS accredited Quality Standards Framework (QSF) auditing scheme which is an outcomes- based scheme that drives quality and safety of service and supply.

TSA Suite 8, Wilmslow House, Grove Way, Wilmslow. SK9 5AG Tel: 01625 520320 | Email: admin@TSA-voice.org.uk | www.TSA-voice.org.uk | Twitter: @TSAvoice TEC Services Association C.I.C. Registered in England & Wales No.11116454. VAT Registration No: 284 9061 75 The QSF comprises of 10 common standards which covers:

• User and Carer Experience
• User and Service Safety
• Effectiveness of Service
• Information Governance
• Partnership Working and Integrated Services
• The Workforce
• Business Continuity
• Ethics
• Performance and Contract Management
• Continuous Improvement and Innovation

and 6 Service Delivery Modules of which TEC Monitoring is one module.

The Key Outcomes for the TEC Monitoring module is:

TM01 Providers will ensure that monitoring services are tailored to meet individual need. TM02 Providers will have demonstrated that call handling will be delivered to meet the needs of each service user.

Sitting beneath these Key Outcomes are a further 28 minimum criteria that Service Providers must comply with to become certified.

Appello Careline Ltd is a QSF certified organisation that undergoes an annual audit to ensure compliance with the scheme. As part of this process, the organisation completes both the Common Standards and the TEC Monitoring Service Delivery module.

Introduction I have read and noted the circumstances and the points you have highlighted regarding the incident provided in your report and requested that TEC Quality Ltd (mentioned above) investigate this matter, in their capacity as our quality and safety standards body. This investigation was necessary, to fully understand the circumstances of the incident and to take the views of the main party involved in the incident into account before we were able to make recommendations on actions to be taken.

TSA Suite 8, Wilmslow House, Grove Way, Wilmslow. SK9 5AG Tel: 01625 520320 | Email: admin@TSA-voice.org.uk | www.TSA-voice.org.uk | Twitter: @TSAvoice TEC Services Association C.I.C. Registered in England & Wales No.11116454. VAT Registration No: 284 9061 75 The Matters of Concern raised by the Coroner ( known as YZ within the report):

1) YZ’s presentation with Huntingdon’s Disease involved altered pain pathways/responses, slurred speech, lack of or reduced insight, tendency to apathy and self-neglect and impaired cognitive processing.

(2) These are aspects of presentation that may be present in a wider group of other end-users of careline services (for example those with dementia) and are not limited to end-users with Huntingdon’s Disease.

(3) I found there was a missed opportunity to obtain life-saving medical assistance that was attributable to YZ’s impairments arising from Huntington’s Disease.

(4) YZ had called for assistance, but the operator failed to identify that he had a major injury with significant blood loss.

(5) The interaction was very brief, YZ contributing only a few words, and I found key information might have been elicited if YZ had been given more time, asked to repeat his unintelligible opening words, or had been asked open and/or more specific closed questions.

(6) I found the operator who answered the call was trained and had followed the protocols that were in place for him at that time. He was not a clinician. His management of the call was in line with the guidelines applicable to his work (Appello Careline Limited guidelines, and the guidelines of the Telecare Services Association, which are followed by most of the careline services industry).

(7) After YZ’s death Appello Careline Limited quickly and proactively reviewed their procedures and amended their call protocols. At inquest they accepted the offer of the Huntingdon’s Disease Association to work with them to identify questioning methods or protocols that might further reduce the risk of similar outcomes in future.

(8) The Telecare Services Association was not a recognised interested person in YZ’s inquest.

(9) I am bringing a risk formally to their attention with this report. The risk is to careline users with similar presentations as YZ if the Telecare Services Association’s guidelines continue unamended.

TSA Suite 8, Wilmslow House, Grove Way, Wilmslow. SK9 5AG Tel: 01625 520320 | Email: admin@TSA-voice.org.uk | www.TSA-voice.org.uk | Twitter: @TSAvoice TEC Services Association C.I.C. Registered in England & Wales No.11116454. VAT Registration No: 284 9061 75 TEC Quality Investigation and Findings:

The organisations we were able to discuss this case with were:
• Appello Careline Ltd

The discussion with Appello Careline Ltd included a review of the voice recordings from the incident. The coroner’s report highlighted missed opportunities to identify the appropriate response through further investigation at the time of the alarm call.

Although was known to Appello as having Huntingtons’s Disease, this did not prompt the Operator to seek further clarification through additional open questioning during the alarm call. Upon reviewing the voice recordings, it was evident that the Operator failed to clarify the few unintelligible words spoken b during the brief alarm call therefore missed the opportunity to seek further assistance and a physical response.

Discussion with Appello Monitoring From meeting with Appello and subsequent email exchanges, it is apparent that Appello Careline Ltd have investigated this incident internally and have already put into action some additional changes to their internal processes namely:

The Appello call handling process prior to this incident was to start the conversation with one “open” and one “closed” question:

“Hello , what’s your emergency” – Operator to ascertain if needs help.

Second question to – “Ask if is ok”.

Rationale for this approach was, by asking two separate questions, to ascertain sufficient information eliciting two separate responses to conclude that the Operator could close the call down without further action.

It is evident from the voice recordings that one open question was asked and two closed questions, however, despite the responses being faint, did supply responses to the closed questions that indicated he required no further assistance.

To improve the call handling process following this incident Appello have worked with the Huntington’s Disease Society to support the change in process to ensure the conversation starts with two “open” questions upon receipt of an alarm call and further clarification of wellbeing:

TSA Suite 8, Wilmslow House, Grove Way, Wilmslow. SK9 5AG Tel: 01625 520320 | Email: admin@TSA-voice.org.uk | www.TSA-voice.org.uk | Twitter: @TSAvoice TEC Services Association C.I.C. Registered in England & Wales No.11116454. VAT Registration No: 284 9061 75

“Hello , what’s your emergency”.

“What is the reason for your call today”

Confirm with the service user if assistance is needed and reason for the activation.

IMPORTANT – Call cannot be closed without fully confirming the Service User’s welfare.

The rationale for this above approach was to improve a person-centred approach to call monitoring particularly in respect of a Service User who may have a chronic illness that could impede their ability to respond or make clear the response they required including emergency response.

Following the internal review, Appello Careline Ltd have:

• Updated their call handling process to provide a new script for TEC Operators that includes two ‘open’ questions and to ensure clarification of the Service User’s welfare on all calls.
• Completed internal training of the updated call handling policy and process with all TEC Operators.

During our meeting, we explored further learning opportunities for Appello and the TEC Sector as a whole. As more individuals choose to live at home with chronic and life-threating conditions, ensuring their safety and wellbeing remains a priority.

For TEC Monitoring services, maintaining accurate medical information which includes a process for reviewing this information, enables TEC Operators to deliver a person-centred approach when handling alarm activations. While the role of a TEC Operator is non-clinical, a foundational understanding of Huntington’s Disease and other chronic illnesses equips them to ask the necessary follow-up questions, ensuring the best possible support and outcome for the Service User.

Appello Careline Ltd has identified additional conditions and relevant organisations, actively collaborating with the Huntington’s Disease Society to gain insights into best communication practices when engaging with individuals who may experience cognitive impairment.

All QSF certified TEC Providers are equipped with a ‘Decision Support Tool’, designed to assist Operators in asking appropriate questions based on the level of emergency and the Service User’s medical condition to assist with identifying the most appropriate response. Originally developed in collaboration with NHSE, this tool was created to support Operators to direct non-emergency medical incidents to local NHS Urgent Community Response Teams however, it is effective and well-integrated

TSA Suite 8, Wilmslow House, Grove Way, Wilmslow. SK9 5AG Tel: 01625 520320 | Email: admin@TSA-voice.org.uk | www.TSA-voice.org.uk | Twitter: @TSAvoice TEC Services Association C.I.C. Registered in England & Wales No.11116454. VAT Registration No: 284 9061 75 with TEC operations for both emergency and non-emergency incidents, and upon review could accommodate additional pages to include the addition of cognitive medical conditions.

Conclusion From the details of the Coroner’s report and the discussions we have had with Appello Careline Ltd who provided the TEC Monitoring service for I can make the following conclusions:

On this occasion the lack of questioning and knowledge of Huntingtons Disease, by the TEC Operator, to ascertain the Service User’s welfare on the incoming alarm call attributed to a missed opportunity to obtain life-saving medical assistance.

That Appello Careline Ltd have made steps to address issues including review of their internal call handling procedures alongside partnership working with the Huntingtons Disease Society and to address updated TEC Operator training across the organisation.

Appello Careline Ltd have worked openly with the TSA to address future learnings to improve the TEC Sector as a whole.

TSA Comments and Actions We do believe that lessons can be learnt from this incident that will prevent future deaths.

The TSA Quality Standards Framework (QSF) is designed to minimise errors and promote best practices within the sector. TEC Quality hold a unique position within the sector. As the leading TEC standards body, findings from cases such as Regulation 28 notices can be included in future mandatory CPD workforce training that aligns with the QSF. While participation in the scheme is voluntary, we actively encourage Commissioners to specify the QSF in tenders and recommend that procurement bodies do the same.

TSA remains committed to advocating the QSF adoption, working to raise its profile and reinforce the importance of adherence to these standards. By ensuring compliance, we aim to reduce risks and help prevent incidents like that of from occurring in the future.

The QSF module for TEC Monitoring ensures that Service Providers implement robust risk assessment processes and regularly re-evaluate Service User needs. Our Auditors ensure that evaluations are conducted and that key processes are effectively embedded into practice through the audit process. Following any incidents, measures are in place to guarantee that critical data, such as medical conditions, remains accurate and up to date, supporting effective service delivery and informed

TSA Suite 8, Wilmslow House, Grove Way, Wilmslow. SK9 5AG Tel: 01625 520320 | Email: admin@TSA-voice.org.uk | www.TSA-voice.org.uk | Twitter: @TSAvoice TEC Services Association C.I.C. Registered in England & Wales No.11116454. VAT Registration No: 284 9061 75 decision-making. By maintaining reliable information, TEC Operators can deliver informed, responsive call handling, enhancing service quality and safety. This process is a key component of any effective TEC solution.

As part of our next QSF scheme change process, we will review the learning from this report to further strengthen criteria for all QSF certified organisations. A key focus will be on refining questioning techniques for TEC Operators when handling alarm calls, ensuring improved accuracy and responsiveness. This will also include the review of programme two, alongside contributions from the TEC Sector and external stakeholders, of the TEC Quality CPD mandatory workforce training for all frontline TEC staff and a review of the ‘Decision Support Tool’ for TEC Operators.

I hope this demonstrates that we are doing all we can to learn and change behaviours following such a sad incident.

If you require further information, please do not hesitate to contact me.