Ramona Harbott

Dear Madam Coroner

Regulation 28: Report to prevent future deaths in relation to Ramona Doreen Harbott

I am responding to the Regulation 28 Report issued on 19 December 2025 following the inquest into the death of Mrs. Ramona Doreen Harbott. The inquest concluded on 8 December 2025.

Barchester Healthcare (‘Barchester’) deeply regrets the death of Mrs Ramona Harbott and the distress this has caused her family.

Following this very sad incident we have made widespread changes to the provision of care and services at Windmill Manor Care Home. For the purpose of this response, we have considered the concerns raised by you and where possible we have grouped together details of assurance measures where these appear to deal with more than one area of concern.

Coroner’s Concerns

The matters of concern are:

a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff. Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore. Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week.

b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk, use of preventative measures, skin monitoring, pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited.

I have addressed the concerns below:

Completion of action plan of improvements

As you are aware an Action Plan of improvements was implemented following this incident and a copy of that was submitted to court on 12 November 2025. Further actions following

the hearing on 13 November were confirmed in the signed statement of the Regional Manager submitted to the court on 5 December 2025.

Whilst some of the actions are completed such as replacement of the General Manager, appointment of a Regional Manager and dismissal of the Deputy Manager, other actions are necessarily part of day-to-day documentation and process which will remain embedded and ongoing to ensure a robust approach to the planning and management of the needs of our residents.

Otherwise, I can confirm completion of actions referred to as follows:

• Replacement of General Manager.
• Dismissal of Deputy Manager due to gross misconduct and referral to the NMC.
• Appointment of Regional Manager.
• Block of Bank Nurse involved in incident .
• Introduction and embedding of electronic records and case management system ‘Enable’.
• Review of investigation carried out post incident and subsequent disciplinary actions and outcomes.
• Post inquest reflective sessions with staff carried out by Regional Manager with focus on the matters of concern raised by you during the inquest and in your findings and conclusion delivered on 8 December 2025.
• Training and Supervision sessions took place with all staff at the Home on 22nd October 2025, and 18th December 2025 led by the Regional Operational Trainer and Clinical Development Nurse. As previously advised, the training focussed on pressure area care and management of pressure ulcer/wounds. During the training there were refresher sessions on the Barchester Tissue Viability and Skin Tear Policy and specific focus on early and appropriate management of risk, use of preventative measures, skin monitoring, pressure ulcer treatment and record keeping. The Clinical Development Nurse assigned to the Home uses the SSKIN bundle framework approach to promote comprehensive risk assessment, monitoring and care as a tool in pressure ulcer prevention. Early identification of skin compromise through regular checks is reinforced as part of daily care. Training sessions included knowledge testing and question and answer sessions prior to completion. Particular note of the evidence at inquest of the Tissue Viability Nurse Consultant from the NHS Trust hospital was taken by the Regional Manager who as you are aware attended the inquest throughout. She has disseminated the evidence of the hospital nurse to the Home staff as part of a best practice approach to management of risk to skin integrity.
• The Clinical Development Nurse now visits the Home on a weekly basis to review the approach to the management of risk to skin integrity and care and treatment plans in place where skin damage has been identified for any resident. She checks that wound assessment and categorisation is being completed correctly with review of wounds by staff in person supported by photographs. She attends the daily stand-up meeting during her visit to follow up on assessments and referrals and any clinical concerns. She is also available for advice and assistance to all staff outside these visits and can review concerns on an ‘as needed’ basis. She has reported an improvement overall in the approach of staff and their recognition of the importance of early interventions and comprehensive treatment plans.
• The Regional Operational Trainer and Clinical Development Nurse have attended the Home on several occasions to carry out observations and monitoring and to identify any further areas for improvement for the clinical team. Visits took place on 7,10, 15 and 22 October. On 15 October 2025 the Clinical Development Nurse attended the Home to review equipment used by staff to support resident care needs. A group session with staff was held to discuss availability of equipment, appropriate use and processes and procedures to assess need and request equipment including pressure relieving mattresses. During an observation visit on 22 October 2025 there was a focus on Moving and Handling techniques used by staff at the Home. No concerns

were identified with staff using appropriate procedures. During the visits, there were sessions arranged with the Home team to discuss the importance of regular repositioning of residents. Group supervisions of all staff were completed during the visits.
• Advice has been provided by the Regional Operational Trainer and Clinical Development Nurse in respect of the use of beds and mattresses as vital equipment for the management of skin integrity and as an aid to prevention of damage to skin. Full staff training has been carried out with the Head of Maintenance at the Home in respect of the use of dynamic air mattress settings and how to use these appropriately and the importance of regular checks. Refresher training has also been provided to the Home team in respect of how to access mattress replacements in the event of a mattress failure occurring out of hours. Audit

i. There is a robust admissions process in place which the General Manager controls and monitors throughout the stages from pre-admission to admission. This ensures that all prospective resident needs are identified prior to admission and appropriate training for staff and equipment for the individual is in place prior to and on admission. A robust pre-admission assessment is completed, both written and electronically. If there are any specific risks/complex care identified they would need the approval of the Regional Director before a place in the home would be offered. This ensures that an appropriate level of care is in place from the outset with a dedicated care plan to accommodate risks. The General Manager monitors changing needs and provides direction through the senior care team.

ii. All residents are part of the Resident of the Day process. As part of Resident of the Day process, all assessments, risk assessments and care plans are reviewed monthly and updated as required if needs change. This is completed by the Nurse leading the shift.

iii. The General Manager daily walk around of the Home includes ad hoc sampling of resident care records and supporting documentation. This audit tool also directs the General Manager to approach and question both residents, families and staff to identify any concerns. Any actions identified are discussed at the daily stand-up meeting and then carried forward to the next meeting, to ensure review of completion.

iv. A monthly documentation audit is also completed by the General Manager, which enables them to monitor care planning for all residents., Generally, there has been an improvement in the quality and frequency of recording of care interventions and evidence of robust triangulation of decision making and monitoring and response to changing care needs.

v. A monthly skin integrity audit is completed by the General Manager which reviews all residents deemed as ‘high’ or ‘very high’ risk of pressure damage. This looks at care interventions and equipment in place, including mattresses and chair cushions. The audit also reviews the care plans and the completion of Waterlow scores in line with the Resident of the Day process. The Regional Manager completes this audit bi- monthly to add increased oversight and safety netting and to identify any further interventions required for residents.

vi. In accordance with Barchester procedures the Home holds a monthly clinical governance meeting. Following the appointment of a new General Manager at the

Home, this has been completed bi-weekly to provide increased oversight. This will review any high risk residents and all tissue viability issues and care in the Home.

vii. Following the implementation of the bi-weekly clinical governance meetings, there has been a noticeable improvement in the understanding of the importance of consistent and effective management of our residents’ risks and care needs including skin integrity. This is measured through monthly skin integrity audits completed by the Regional Director, General Manager and Clinical Development Nurse. The audits comprise of a review of ‘Waterlow’ scores which indicate risk of pressure injury. It correlates this risk in line with interventions to mitigate, such as repositioning regimes. The monthly documentation audit that is undertaken by management in the care home is reviewed by the Regional Director to ensure that actions identified have sufficient timeline and follow up for completion. In addition, there is enhanced and dedicated training undertaken by staff and improved documentation and oversight by the General Manager resulting from the implementation of the electronic records system, ‘Enable’.

viii. During the clinical governance meeting, any external referrals are discussed and these are documented electronically on the system enabling all levels of management to maintain oversight. The clinical governance meeting minutes are shared within the service and uploaded onto the service’s clinical governance system which enables the senior management team to review these remotely and to raise any concerns with the Home as appropriate.

Windmill Manor Care Home

(i) As part of the lessons learned for Windmill Manor Care Home it was highlighted that staff required further training from the organisation’s Clinical Development Nurse in the approach to management of skin integrity. Following completion of the inquest and receipt of the Regulation 28 Report, the Managing and Regional Directors made arrangements for further refresher training to be delivered at Windmill Manor Care Home with follow up by the Regional Manager and Quality Assurance Team. This has already taken place and will be repeated at intervals as necessary. As part of the training delivered, the specific concerns arising out of this case were used as a case study to demonstrate how early recognition and management of risk to skin integrity and damage and robust documentation should lead to measures to mitigate increased risk. There has been an additional emphasis on the requirement to maintain robust handover documentation on a daily and weekly basis.

(ii) It has also been recognised that staff at Windmill Manor Care Home required further training on the Barchester Tissue Viability and Skin Tear Policy. If staff had followed the policy in this case, they would have followed the prompts to ensure that every aspect of the risk review was undertaken along with the immediate action following identification of risk of skin damage. This includes early recognition and management of risk and consideration of the equipment and monitoring and repositioning regimes which should be revisited daily. This training has taken place and will be repeated as necessary. This has proven effective as those at higher risk of deterioration to skin integrity have had effective mitigation measures put in place, as evidenced on the online documentation system, ‘Enable’.

(iii) The General Manager at Windmill Manor Care Home has been provided with dedicated support from the Managing and Regional Directors and the Clinical Development Nurse during the recent period of change at the home. When changes to a resident’s clinical status are identified, including deterioration to skin integrity, these are added to the online systems which immediately notifies the Clinical

Development Nurse and Regional Director. This allows increased oversight and assessment of triangulation, including categorisation of wounds and associated care planning and treatment regimes. This increased oversight has demonstrated improvement in the detection of issues and prompt investigation of incidents. The General Manager has developed a strong relationship with the care team through regular staff meetings, daily ’Pulse’ meetings and daily stand-up meetings to discuss events occurring within the service and any resident clinical concerns. The bi-weekly clinical governance meetings, address recent changes to resident’s skin integrity, safeguarding issues, weight loss or general clinical deterioration. This is attended monthly by the supporting Clinical Development Nurse who offers, advice, clinical guidance and any further clinical training required for the care team. Staff have been supported to complete regular knowledge checks which enables the wider team and General Manager to identify any knowledge gaps to be able to tailor their support delivery. This has improved staff confidence and enhanced their ability to implement preventative measures to support individuals within our care.

(iv) All staff within the service have completed their training on the electronic records system which has supported them to ensure they understand the process of recording ‘at point of care’. The introduction of e-care documentation has given greater oversight to the General Manager and central supporting functions of the organisation and facilitates remote access on a 24/7 basis. The Clinical Development Nurse reviews the records on ‘Enable’, alongside the clinical governance system. The clinical governance system is a system that allows systematic review of care practices such as documentation of skin integrity, weight monitoring, infections and accidents and incidents. The Clinical Development Nurse focuses her monthly visits to the findings to enable her to tailor her support to the needs as identified. The implementation of the electronic records system has given the General and Regional Managers improved oversight of staff action or inaction and enables them to identify shortfalls in staffing skills and abilities. The electronic records system has a dashboard which can be used to view all care domains for all the residents in the home in discrete sections. The General Manager can therefore swiftly and easily review all residents’ wounds within the home and ensure that these are categorised correctly, and all relevant risk assessments and care plans are in place. All wound assessments are now completed electronically.

Thank you for raising your concerns. I hope that the content of this letter provides sufficient assurance that Barchester Healthcare take the concerns raised seriously, has taken action following the death of Mrs Ramona Harbott, is committed to ongoing and continuous improvement and is auditing and monitoring compliance regularly and robustly. We accept your concerns and continue to work to improve the service we provide. Should you have any questions or concerns or comments, please do not hesitate to contact me directly.