1 RESPONSE TO REGULATION 28 CORONER’S REPORT TO PREVENT FUTURE DEATHS
1. THIS RESPONSE IS MADE ON BEHALF OF London Borough of Bromley Council
2. REGULATION 28 REPORT This response follows a report by Ms Liliane Field, Assistant Coroner, for the Coroner area of London Inner South 3 INVESTIGATION and INQUEST On 10 February 2022, the Coroner commenced an investigation into the death of James Collier SIDDONS, aged 91 years. The investigation concluded at the end of the inquest on 24 January 2025. The conclusion of the inquest was that Mr Siddons died on 31 January 2022 at University Hospital Lewisham, London (UHL). The medical cause of death was recorded as 1a Sepsis 1b Aspiration pneumonia and pyelonephritis 2 Ischaemic heart disease, osteoporosis, previous stroke, Alzheimer’s disease. The coroner concluded with the following narrative: Mr Siddons died in hospital from sepsis to which he had become increasingly vulnerable due to deteriorating life-limiting medical conditions. He had been admitted to hospital having sustained a fractured humerus whilst resident at a nursing home. 4 CIRCUMSTANCES OF THE DEATH Mr Siddons had been admitted to UHL on 18 January 2022 having sustained a fracture of his left humerus at Sloane Nursing Home, Beckenham. The precise circumstances of the injury have not been established. Mr Siddons suffered from a significant number of co- morbidities including but not limited to Alzheimer’s disease, osteoporosis, ischaemic heart disease and previous stroke resulting in very severe frailty. Mr Siddons made a good recovery from the facture and was waiting for a new nursing home placement when he developed raised inflammatory markers suggestive of infection. There was radiological evidence of aspiration pneumonia to which he was vulnerable due to dysphagia as a manifestation of late-stage Alzheimer’s disease. He had also developed pyelonephritis. He died suddenly from sepsis, his condition having remained stable, despite appropriate treatment with antibiotics, on 31 January 2022. 5 CORONER’S CONCERNS The MATTERS OF CONCERN set out by the Coroner are that: Mills Family Ltd (Mills)
1. The investigation into the circumstances of Mr Siddons suffering a fracture was flawed such that lessons that might prevent an incident which could result in a future death have not been learnt :
a. It failed to explore all the scenarios that might have accounted for fracture.
b. It was in part delegated to a deputy manager without terms of reference
c. Mills Family senior management was not involved
d. The investigation’s conclusions were based on assumptions
2. Mills have a policy setting out a broad overview of the principles of investigation

2 but no detailed guidance on how an investigation should be conducted within its organisation
3. There is no routine investigation training for managers London Borough of Bromley (LBB)
4. Mills did not receive the request for the provider led report from LBB until almost a month after the incident. The investigation was started promptly but had to be conducted without Mills being satisfied that all the relevant issues were known 6 ACTION TAKEN/TIMESCALE In respect of the Coroner’s concern (4)- Mills did not receive the request for the provider led report from LBB until almost a month after the incident. The investigation was started promptly but had to be conducted without Mills being satisfied that all the relevant issues were known
-Following identification by the Local Authority that the Provider Lead Enquiry (PLE) was not shared within expected timescales, a discussion was held with the Social Worker who was managing the s42 safeguarding enquiry at the time on the 31/1/25. It transpired that the worker only had a very general recollection of the case due to the amount of time that had passed. (2yrs 10 months) The worker felt that a contributing factor to the delay in sharing the PLE was likely to be that at the time, LBB were transitioning to a new database and the worker and the SAM (safeguarding adults’ manager) were encountering difficulties with the new IT system. The LBB accept that the PLE wasn’t sent out in a timely manner. On an individual level subsequent discussion was held to highlight the importance of dealing with safeguarding concerns, with specific reference to PLEs, in a timely manner with the Social Worker, which the worker acknowledged. Steps have been taken to speak to the line manager, and I’m assured by the Social Worker’s current SAM that what happened at this time is not indicative of the worker’s current practice, which is of a good standard, and the issues raised here are not typical or ongoing. Processes have been put in place to provide checks and balances on safeguarding decision making and ensure that the appropriate actions have been taken. The Consultant Lead Practitioners (CLP) provide practice support to ensure that appropriate and timely actions have been taken, which could include the PLE form. On an organisational level, there is nothing to suggest that delays in sharing PLE forms are a wider concern, and this appears to be an isolated incident. That said, LBB is committed to continuous learning and system enhancement. On April 14, 2025, we will launch our Prevention and Intervention Service, which includes a Safeguarding Hub. This Hub, staffed by dedicated and experienced practitioners, will respond to safeguarding referrals and determine whether a Section 42 Safeguarding Enquiry as outlined by the Care Act 2014 is required. The Safeguarding Hub will manage all initial information gathering and take immediate action to ensure the person's safety, working closely with both statutory and non- statutory partners, as well as the individual and/or their representative. The Local Authority are also going to embark on a review of the contents of the PLE form.

3 7 THIS RESPONSE HAS BEEN PREPARED BY Head of Service Learning Disability & Shared Lives 8 DATE OF RESPONSE
28.3.25

The Mills Family Ltd Fallowfield, Ashfield Lane, Chislehurst, Kent, BR7 6LQ. Tel: 020 8467 2781 Email: info@millscare.co.uk Mills Family Ltd Company No: 03591061 CORONER FOR INNER SOUTH DISTRICT GREATER LONDON Southwark Coroner's Court, 1 Tennis Street, Southwark, SE1 1YD Action Plan in response to concerns raised by Coroners Regulation 28 Report to Prevent Future Deaths following the conclusion of the inquest into the death of Mr Siddons 31/01/2022 Matters of Concern Raised by the Coroner Action to be taken By whom/when
1. The investigation into the circumstances of Mr Siddons suffering a fracture was flawed such that lessons that might prevent an incident which could result in a future death have not been learnt
a. It failed to explore all the scenarios that might have accounted for fracture.
b. It was in part delegated to a deputy manager without terms of reference
c. Mills Family senior management was not involved
d. The investigation’s conclusions were based on assumptions
1. To re-emphasise to all managers and deputy managers that all serious incidents should be notified to the senior management team in line with company policies. Further, re-emphasise that input from the Director of Care, Mandy Finn, should be sought before any investigation report or serious incident report is finalised and circulated.
a. Use the new Root Cause Analysis policy to explore all scenarios.
b. The new Serious Incident Notification Policy states the home Manager will investigate incidents as deemed appropriate by the RCA system.
c. All investigations and PLER’s are to be signed off by Mandy Finn.
d. Managers to Base all conclusions on evidence and not upon opinion and/or surmise completed 07/03/2025
2. Mills have a policy setting out a broad overview of the principles of investigation but no detailed guidance on how an investigation should be conducted within its organisation
2. All managers to receive training on new policies regarding:
a. Accident & Incident Reporting Policy & Procedure
b. Serious Incident Notification Policy & Procedure
c. Root Cause Analysis Policy & Procedure completed 07/3/2025
3. There is no routine investigation training for managers All managers to receive training to improve investigation skills from:
a. Croner’s
b. Bromley Adult Safeguarding Croner training was completed on 18/03/2025 LBB Awaiting new training calendar for April 2025 Director 19/03/2025