Bonita Cleary

1 Regulation 28 Action Plan – Delahey’s Nursing Home and Curo Care Collective Coroner: Alan Anthony Wilson Date of Report: 1st of March 2026 Regulation 28 Reference: Service AƯected: Curo Care Delahey’s Ltd. Lead Responsible Person: Operations Director and Ainslie Fotheringham Registered manager Matter of Concern  Bonita Cleary died during a choking episode, and this is potentially reversive cause  Notwithstanding there was a DNR CPR authorisation in place, CPR ought to have been commenced  On balance of probabilities, this would not have served Bonita’s life, but for other vulnerable residents in a care setting eƯective and timely CPR may prevent death  The coroner is concerned that there is a lack of awareness amongst care and nursing staƯ in Curo Care and the care sector more widely about when CPR should be attempted, and that residents with a realistic chance of surviving may die as a result of a cause which was in fact potentially reversible

2 Delahey’s Nursing Home Action Taken The learning from this incident has been shared across all homes within the organisation to ensure consistent understanding of DNACPR decisions and the requirement to commence CPR if a reversible cause, such as choking, is present. Action Date Evidence Responsible Notifications sent to CQC and Safeguarding 12/10/2025. CQC statutory Notification resent to CQC 18/10/25 CQC receipt reference number NOT-013368649 Root Cause Analysis Investigation for Serious Incident Concluded 15/02/26 Appendix 1. Incident Report Colleague Welfare: team reminded that they have free access to Wisdom, the digital wellbeing platform linked to Curo Care’s Employee Assistance Programme. This includes a 24/7 confidential counselling helpline and oƯers additional support for colleagues aƯected by distressing events. At all handovers for a week following the incident Wisdom poster with contact details in staƯ room StaƯ recompleted E-learning modules in Choking, IDDSI, Dysphagia, Seizure Management and Basic Life Support. All colleagues read and signed policies: Seizure Policy and Basic Life Support Policy. 15/10/2025 – 22/10/2025 15/10/2025 -23/10/25 Appendix 2. training matrix Signed sheets are available for policy reading confirmation if required All Colleagues completed Assisting Residents to Eat and Drink Competency assessments. 14/10/2025 – 22/10/2025 Appendix 3. Competency Assessment – Assisting Residents to eat and drink. Face-to-face First Aid training (6 hours per session) commissioned for all colleagues, covering choking management, airway management, BLS, seizure response and escalation protocols.
*Included a section on reversible causes 24 - 25th Feb 2026 Awaiting First Aid Certificates

3 Both the nurse and care assistant have reflected and completed a written reflective accounts Reflection from Carer received 19/10/2025, Nurse reflection account received 18/02/2026 Appendix 5. Nurse reflection Appendix 6. CA reflection Group supervision sessions were held with all colleagues to: Reinforce the importance of high-quality documentation and to thank staƯ for the detailed records within BC’s care plan Provide further clarification and discussion around DNACPR decisions and reversible causes  6 sessions held to cover all staƯ between the dates of 15/01/26 - 21/01/2026 Appendix 7. Group Supervision Template for DNACPR A dedicated section on DNACPR and reversible causes has been added to all staƯ induction programmes at Delaheys Temporary fix – added to the home’s induction from February until new company induction paperwork is developed to include guidance on DNACPR and reversible causes. Appendix 8 Induction. New colleagues will receive also training and complete a competency assessment to ensure understanding. A LifeVac Wall-Mounted Airway Clearance Device Kit was purchased and introduced within the home. 05/11/25 Appendix 4. copy of LifeVac invoice

4 Curo Care Group Learning and Improvement Actions Following this incident, a full review and root cause analysis were undertaken to understand the circumstances and identify learning. Immediate actions were implemented within the home and across the wider organisation to strengthen staƯ understanding of DNACPR decisions, particularly in relation to reversible causes such as choking, and to reinforce both choking prevention and emergency response procedures. The actions below set out the steps taken across the organisation to address the coroner’s concerns and reduce the risk of a similar incident occurring in the future. Action Specific Steps Responsible Person/s Completion Date Evidence of Completion How Impact Will Be Monitored Awareness and learning: ensure all Registered Managers are aware of DNACPR and reversible causes DNACPR Circular from Care Sector Clinical Lead - South Cumbria & Morecambe Bay NHS Lancashire and South Cumbria Integrated Care Board 09/01/26 High priority email sent to managers
*Email available if required With follow up and discussion Face to Face at next managers’ meeting Follow up with managers face to face to ensure DNACPR and reversible causes is understood A workshop was held at the January Home Managers’ meeting to review the incident and revisit DNACPR understanding. The Delahey’s Manager shared her experience, and key learning points from the Inquest were discussed. 26/01/26 Appendix 9 Managers’ Meeting Minutes (other non- relevant actions and discussions redacted) Discussed at meeting and again at subsequent operations director home visits throughout February Cascade the information to staƯ across the group Managers cascaded the learning to their teams using a variety of methods including supervisions, one to ones, staƯ meetings, huddles, flash meetings and handovers. Home Managers 26/01/26 – 17/02/26 Response email from all managers confirming completion sent to operations director 18/02/26 Spot checks in home visits by operations director and regional operations manager

5 Provide care home teams with a reference leaflet Managers shared an information leaflet for staƯ to refer to in the homes. Ops director shared the link that CQC sent with the HMs so that they can print the document and make available to staƯ. Home Managers 17/02/26 Appendix 10. Leaflet. Email confirming completion sent to operations director Spot checks in home visits by operations director and regional operations manager Confirm colleague understanding A DNACPR competency has been developed and will be completed with all staƯ, with signed copies retained on file, (please note: a draft version is attached) Home Managers 17/02/26 Appendix 11. DNACPR Competency Assessment This competency check is being prioritised, and all colleagues will have one in place by 31/03/26. Spot checks will be undertaken during senior management visits Reinforce that 999 should be called immediately if choking is not relieved quickly. Reinforce through meetings and handovers that emergency services should be contacted promptly where choking is not immediately relieved. Home Managers First Aid Training Provider ViTa 31/03/26 Handovers and team meeting notes confirming that the guidance has been communicated to staƯ. StaƯ knowledge checked through supervision, competency assessments and informal questioning during spot checks. Incident report reviews will confirm that 999 is called promptly where choking incidents occur. Introduce LifeVac equipment across all homes in the group Emergency equipment locations will be reviewed and communicated so that colleagues can access equipment immediately in an emergency. Training will be undertaken by all staƯ Home Managers 31/03/26 All homes will have a LifeVac in place StaƯ training and understanding will be recorded – Appendix 14. StaƯ will have access to an airway clearance device that may help where standard choking procedures have been unsuccessful.

6 Ensure all new colleagues are aware of DNACPR and reversible causes when they join the company DNACPR and reversible causes to be part of new induction, currently under development Home Managers 30/04/26 Under development New induction paperwork is being developed to include guidance on DNACPR and reversible causes. NB in the meantime, new colleagues will receive training and complete a competency assessment to ensure understanding. Company external training to include DNACPR and reversible causes Shared information with the company that delivers First Aid training (ViTa) so they can update the training for Curo and others in the sector Verbally 26/01/26 Formal email sent to 04/03/26
*Email available if required Response – agreed to incorporate and they will also contact QUAL SAFE, the awarding organisation that develops and accredits first aid, health & safety, and pre- hospital care qualifications (regulated by Ofqual) with the recommendation to incorporate formally. Colleagues will have a greater level of practical knowledge and understanding of CPR, including when it must be commenced. If QUAL SAFE takes this into account, the knowledge will be widespread Company E-learning to needs to include DNACPR and reversible causes Your Hippo to be informed that reversible causes should be part of basic life eLearning training. This should impact other care providers using By phone on 03/03: YH agreed to incorporate this into Basic Life Support E-learning.
*Emails available if required Follow up email sent 04/03/26 to Colleague knowledge about DNACPR and reversible causes will be widely understood, reinforced, and accessible to all colleagues. This will also be renewable training.

7 Create a specific DNACPR Policy New DNACPR policy written to be shared with all new and existing staƯ once implemented Written: 02/03/26 Appendix 12. Sent to QCS who provides policy templates, and guidance for regulated care providers such as care homes. A DNACPR specific policy will provide clear guidance to staƯ on what a DNACPR means and when CPR must still be commenced. It supports safe decision-making, protects residents’ wishes, and helps ensure staƯ respond appropriately in an emergency. The policy will be added to Curo homes’ library immediately. However it will be reviewed and added to the wider library Ensure DNACPR Policy is added to library and learning is shared with QCS Add to Curo policy library but inform QCS why we are adding the DNACPR policy so they can write their own which can be shared with other care providers using their policies. Sent to QCS to add to Curo Homes’ library: 04/03/26 Response from QCS confirming they will write a policy and share it with all providers by 13/03/26. Email to on 04/03/26, delivered and read.
* Emails are available Colleagues across the sector will have accessible clear guidance on what a DNACPR means and when CPR must still be commenced. It will support safe decision-making and help ensure staƯ using the policy in all settings respond appropriately in an emergency

8 Care Plans must include a DNACPR reversible causes note Managers to review and update all care plans to include a DNACPR reversible causes note where applicable. Home Managers Emailed instructions to managers on 23/02/26 Target completion date is 31/03/26
*Email available All care plans will contain a reminder to clarify that the DNACPR applies only if the resident’s heart stops naturally and CPR must still be commenced if the cardiac arrest is caused by a potentially reversible event. This note will then be personalised following speaking with the resident/ family/ LPA. This will be checked during quality checks Ensure both choking prevention measures and emergency response guidance are reflected in care plans Care plans for those residents diagnosed with seizures will be reviewed and a note added that states there is potential for seizure during eating, which would cause change in state of consciousness. Note to be added to all other care plans to remind staƯ that if the person becomes unresponsive while eating, it should be treated as a possible choking emergency and to follow the choking response procedure immediately and emergency services should be called promptly (& if cardiac arrest occurs as a result of a reversible cause, such as choking, CPR must be started) Home Managers By 31/03/26 Email instruction issued to all managers confirming the required wording and timescale for completion.
*Email available if required Spot checks and audits of a sample of care plans during senior management visits, report compliance on provider visit record Check of care plan audits during quality checks. Spot checks during provider visits to ensure staƯ are aware of the guidance. Ongoing monitoring of incidents Review of staƯ understanding during DNACPR competency assessments

9 Regular review of residents with known choking risk Choking risk assessments will continue to be reviewed regularly to ensure appropriate supervision, positioning and food texture guidance are in place. Home Managers 31/03/26 Care reviews Care Plan Audits Residents with choking risks will have the right supervision, positioning and food textures in place, reducing the likelihood of choking incidents. Discuss DNACPR limitations with resident and/ or family Discussions with residents and families will include clarification that DNACPR applies only to natural cardiac arrest and does not prevent intervention where the cause is reversible. Home Managers 30/04/26 Care plan entries in reviews to show DNACPR discussions have taken place Care plan audits will confirm DNACPR discussions. Spot checks during management visits Feedback from residents and families during reviews or meetings confirming understanding Incident reviews These actions will be monitored through the company’s governance framework. Compliance will be reviewed through care plan audits, training compliance monitoring, competency assessments, and spot checks made during senior management and provider visits. Any choking incidents or emergency responses will be reviewed through our incident reporting system to make certain that emergency services are contacted promptly and that CPR is commenced where a reversible cause is identified. Learning from incidents will continue to be shared across Curo Care to reinforce safe practice.