Dear Sir

Inquest touching upon the death of Anthony Friend

I write in relation to the Regulation 28 report sent to Bluebird Care Bromsgrove & Redditch regarding the death of Anthony John Friend dated 18 September 2023 and received on 29 September 2023.

Following on from the inquest and receipt of the Regulation 28 report, we have thoroughly reviewed the circumstances surrounding Mr Friend's case, both in relation to Bluebird Care and other health care providers and professionals involved. We are always committed to being an outstanding care provider and will take any feedback on board to improve our processes.

We note that the Coroner has expressed concern that there was no direct contact between ourselves, as the outgoing provider of care, and the incoming provider in this matter and he is concerned that this may have led to important information, such as concerns, not being passed on.

We are conscious that the question of handover processes between NHS Continuing Health Care ("CHC") commissioned care providers arose during the course of the inquest. It therefore may be helpful for us to provide some additional context to this process via this response which may assist in allaying HM Senior Coroner's concern in this regard.

NHS Continuing Health Care (CHC) refers to packages of care that are arranged and funded solely by the NHS Integrated Care Boards for individuals over the age of 18 years who have been deemed to have a ‘Primary Health Need’ and have ongoing complex, intense or unpredictable healthcare needs. These packages are overseen by Clinical healthcare professionals such as Clinical Nurses, and managed by the CHC teams at the relevant NHS Integrated Care Boards.

Bluebird Care (Bromsgrove & Redditch) 3 Millennium Court, Buntsford Park Road Bromsgrove, B60 3DX

Bluebird Care Bromsgrove & Redditch Registered in England and Wales as R D (Bromsgrove) Ltd. Company No. 7099683

The standard practice of handover of a CHC care package between care providers, as was followed in this case, is below:

1. Notice is served on the Hereford and Worcester CHC team by the outgoing care provider;

2. A detailed verbal update and handover is provided by the outgoing provider to CHC's clinical case handlers. This handover would include outlining any areas of concern;

3. The CHC care plan is updated to include any additional information provided by the outgoing provider and this is shared with brokerage to seek a new provider;

4. The new provider will review and assess the patient, request/obtain any information they require (including from the outgoing provider if necessary) and, if satisfied, the new provider will agree to commence care;

5. The outgoing provider will cease providing care, the new provider will commence providing care. The identity of the new care provider is not typically shared with the outgoing provider.

In our experience, the care plans prepared by the CHC clinical case handlers are generally detailed and informative.

Following the inquest, the senior management team at Bluebird Care Bromsgrove & Redditch carried out a ‘Lessons Learned’ meeting on 5 October 2023 to review Mr Friend's case in more detail. The aim of this meeting was to highlight and discuss what went well with his care, what could have gone better and also if there were any improvements to be made to any processes. This meeting provided an opportunity for us to consider the Regulation 28 report carefully.

As part of this meeting, the management team reviewed the detailed care plan that had been prepared by CHC based on information provided by ourselves and provided to Divine Health Care as part of the process of finding a new care provider. Although the handover was from CHC to Divine Health Care and not directly from Bluebird Care to Divine Health Care, all of Bluebird Care’s concerns regarding the sling were very clearly documented within this detailed 14-page document. Our identity as the outgoing care provider was also included within this document. This document was shared with Divine Health Care in advance of them carrying out their assessment and agreeing to take over Mr Friend's package of care.

Bluebird Care (Bromsgrove & Redditch) 3 Millennium Court, Buntsford Park Road Bromsgrove, B60 3DX

Bluebird Care Bromsgrove & Redditch Registered in England and Wales as R D (Bromsgrove) Ltd. Company No. 7099683

As outlined at the inquest, Bluebird Care had concerns regarding the positioning of Mr Friend’s neck whilst being hoisted in the sling, and the possibility of restricting his airways and oxygen levels, as opposed to any concerns around the possibility of Mr Friend falling from the sling. The concerns highlighted by Bluebird Care around the neck positioning are what led to the review of the sling by Occupational Therapists.

Whilst, as above, we do consider that in this case the handover process captured all the relevant information we had to share with the new provider, in an effort to improve this process going forward we have written to Herefordshire and Worcestershire CHC to seek guidance and clarification on the existing handover protocol for care providers when either taking on, or serving notice on, a package of care from CHC, as well as establishing best practice standards to implement any possible improvements. We are dedicated to continue to be a high-quality care provider, and although the circumstances are unfortunate, we want to take this opportunity to work in partnership with other health care professionals to provide the best care and support to all those that we support.

This is important not only for Bluebird Care, but also for all other health care providers supporting users of services that may be transitioning from one service or provider to another, and most importantly for those that we support. Within our letter to Herefordshire and Worcestershire CHC, we also urged them to review the processes in place for all care providers.

Within the letter, we have requested the following steps are taken when a transfer of care provider is being planned or contemplated:

1. If we take on a package of care from CHC, we request that we are informed of the identity of the outgoing care provider so, alongside the care plan provided by CHC, we are able to seek any further information from the outgoing provider that we may require.

2. If we serve notice to CHC on a care package (i.e. we become the outgoing care provider), we would like our information to be provided to the new care company, allowing us to provide a direct handover to them. This would be in addition to any handover we already provide to CHC. We also request that CHC inform us of the new provider to allow us to offer any support/information to them to make the transfer of care as seamless as possible.

3. If we serve notice on a package and a new care provider is sourced, we would like them to be informed by CHC (if we have not already had an opportunity to do so ourselves) that the

Bluebird Care (Bromsgrove & Redditch) 3 Millennium Court, Buntsford Park Road Bromsgrove, B60 3DX

Bluebird Care Bromsgrove & Redditch Registered in England and Wales as R D (Bromsgrove) Ltd. Company No. 7099683

Bluebird Care folder will be in the Customer’s property, containing the customer’s care plan as well as an up-to-date list of tasks for each visit.

4. Where we are the outgoing provider, we would like to offer any new provider the opportunity to observe our care staff carrying out a care call so any necessary observations can be made and any questions asked. We would like to be given notice of when this would occur to ensure a senior member of staff can be present and ensure the most thorough handover possible.

5. We would also value the opportunity, should it be required, to observe a care call being carried out by an outgoing provider if we were to take over a package of care. We have proactively sought out these opportunities ourselves and have found them beneficial when circumstances require this, for example visiting a customer in hospital to make observations prior to returning home, and visiting another customer at home who had an existing homecare provider visiting daily.

6. We would request that CHC share the reasons that an outgoing care provider has served notice on a package. This would allow us to make a more informed decision as to whether we are in a position to take on the package of care, or if we would be likely to experience the same issues and concerns. It also allows us to pay particular attention to these key areas of concern, and conduct the relevant risk assessments to ensure the best and safest care is provided at all times.

7. We would also appreciate if, as a new care provider, we could be advised of any existing appointments the customer may have that would be helpful to know of e.g., occupational therapist visits. Likewise, we would share any appointments we were aware of with CHC, so the new provider could be made aware at the earliest time. From our perspective, this process will not be limited to handovers concerning CHC funded patients and will be followed for all customers that are transitioning to or from our care.

We feel confident that if the above steps are adhered to by all parties, this will lead to better outcomes and a more robust handover process. In particular, the process will no longer be solely reliant upon information being passed between care providers by CHC clinical case managers, as there will be opportunities for direct handover between care providers and a conduit for sharing additional information as required.

Bluebird Care (Bromsgrove & Redditch) 3 Millennium Court, Buntsford Park Road Bromsgrove, B60 3DX

Bluebird Care Bromsgrove & Redditch Registered in England and Wales as R D (Bromsgrove) Ltd. Company No. 7099683

As a care provider, the safety and wellbeing of those we provide service to is paramount. Despite the unfortunate circumstances in which these issues have arisen, we welcome the opportunity HM Coroner has provided for us to revisit Mr Friend's case in order to learn from this experience and implement steps to ensure that we continue to provide the best quality care.

We are aware that this response will be shared with the family. We wish to reiterate our sincere condolences to them on the loss of Mr Friend. We also wish to thank them for their kind comments at the inquest about the quality of care we provided.

Dear Mr Reid,

Re: The Late Anthony John Friend

Regulation 28 report to prevent future deaths - response

Thank you for forwarding on your Regulation 28 report. I have read your report with great care and note the concerns that you have raised during your inquiry concerning the death of Mr Anthony Friend.

In your report, you highlighted the following points of concern, and I will respond to these individually:

1. As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death), an Occupational Therapist employed by HWHCT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s home.

2. During a home visit to Mr. Friend’s address on 2.2.23, noted that the old toileting sling was still being used, made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property;

3. During a home visit to Mr. Friend’s address on 6.3.23, another Occupational Therapist employed by HWHCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague would be difficult to fit, they were nonetheless safer to use. She told the inquest that in hindsight she “should not have allowed [carers] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided;

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4. During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident) in order to assess Mr. Friend for a new sling, noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part;

5. also told the inquest that; (a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 (which they were not); and

(b) she should have contacted his new carers (Divine Health Services Ltd.) after that visit, to discuss their use of the sling.

As a Trust we recognise that at the time of this incident we did not have a robust policy and procedure in place to support our staff in the community with regard to the removal of unsafe equipment. Since the inquest we have formulated a working group to design a new policy around equipment provision and this will cover the necessary steps and procedures for our staff, around timely removal of unsafe equipment from a patient’s home. We will have this new policy signed and operational by the 1st April 2024. A key element will be sharing this new policy which will be completed at individual team meetings and via our global all staff communication emails. Whilst we are developing the new policy we have issued more immediate instructions to staff via a focus on card approach.

As a Trust we recognise that more timely action was required about removal of older slings so we have in partnership with a range of professionals designed a focus-on-card around a step by step guide for staff when they identify unsafe equipment in a patient’s home. This is a direct impact from this serious incident. This will act as a useful reminder document that staff will have access to when visiting patients in their homes and will be a vital part of new starter’s induction packs.

In addition, this card has been shared at operational meetings and globally on 28 September 2023 via our communication team with all Trust staff; a copy of the card is attached for your information. As part of this all clinicians are now carrying laminated cards- “unsafe equipment- do not use”, these can then be attached, photographed using NHS mobile telephones and uploaded to our electronic patient record system (EPR) as evidence, supported by supporting documentation. We recognise that this action may have alerted the care agency in the case of Mr Anthony Friend to not use the equipment. All occupational therapy staff have been educated via a powerpoint presentation on when to use the cards. Staff have reported they are supportive of the implementation of this card.

We have also designed a standardised template letter (a copy is attached for your information) for service leads to send to patients if our clinicians experience resistance when removing equipment from a patient’s home and these will be stored on our electronic patient record.

We are also reviewing our manual handling and sling training that is provided to our staff to ensure this is adequate to support patient needs in the community. We are creating an algorithm to support staff decision making around when and what type of sling is suitable in a variety of situations. We hope to have this operational in the next 3 months. Early discussions have taken place regarding additional online training that illustrates various clinical scenarios, identifying risks and potential equipment that could be recommended.

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We also identified that as a service we need to ensure we have more robust documentation. All staff attend annual clinical records training but since this inquest we have also implemented a quality improvement record keeping audit with our HASE/OT services to ensure compliance with national, regional, professional and local record keeping requirements.

6. At no time do either appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times.

The Trust fully recognises that there was a breakdown in communication between the external agencies involved in the care of Mr Anthony Friend. We have since the inquest designed and introduced a new leaflet (copy attached) that is given to all our patients on initial assessment with the Housing, Adaptation and Specialist Equipment service (HASE). This leaflet has our contact details on. Any family can then easily and accessibly share these details with care agencies if required. This leaflet can also be used by other stakeholders including our GP colleagues when they refer patients to our service.

We have also introduced a new role into our countywide service, this role has a significant bias towards improving communication with our external agencies to prevent occurrences like this happening again. They will be involved in joint visits to clients and will have weekly clinical supervision, where tasks will be delegated to them to support improved communication between HASE and other agencies.

As a Trust we have a robust incident reporting system and are passionate about sharing learning from incidents and complaints with our colleagues in a supportive and compassionate manner with an aim of preventing any further incidents of this nature occurring. The Trust Board are well sighted via the quality report on incidents and complaints.

I hope this reassures you that the Trust has taken action to improve standard operating procedures around unsafe equipment in the community and to improve communication with external agencies through the development of new roles and leaflets. The Trust is committed to learning from this incident to avoid any similar occasions of staff not removing equipment when it is no longer appropriate to be used.

I hope that the above adequately addresses your concerns.

I shall be grateful if you could kindly send a copy of my response to those to whom you copied your Regulation 28 report.