In (hese circumslances it is my stalutory duty to report to you: That special health monitoring devices are being used t0 monitor heallh conditions in palients who are receiving care in (he community. However the care providers do nolt have the necessary training to be able to understand how the device operates, the information it provides and appropriate action to take, dependent on the information from Ihe device, in conjunction with other observations_ At the inquest we heard that this matter was referred t0 (he Safeguarding Adults Board and some learning points had been identified for (he care providers. In particular, was known (hat Mrs Scotl was prone lo urinary tracl infeclions and whilst suffering from these infections Mrs Scolt was known to become confused. A special health monitoring device (Telehealth) was in place The care provider failed to identify (he urinary tract infection prior to admission Thesewere addressed in Ihe Adult Saleguarding Board and

Tearning (Social Worker) (Care Provider Representative) confirmed changes were being considered but could not confirm if recommendations were being implemented. Both the representative of the Safeguarding Adults Board and the care provider consider that a Regulalion 28 report would assist in embedding the Safeguarding Adults Board recommendalions which had counlywide implications_ AcTION SHOULD BE TAKEN In my opinion action should be taken to prevent future dealhs and believe the Cornwall and Isles of Scilly Safeguarding Adulls Board has the power to take such action: To consider recommendalions oullined by (he local Safeguarding Adulls Board in this case are considered countywide in particular wilh (he training and use of Teleheallh.