Peterlee Care Home
Action Planned
Peterlee Care Home will prioritize supporting residents at high risk of falls to bed earlier, reducing their unsupervised time in communal areas. They also stated that existing measures such as staff allocation and sensor use are in place, but requests for 1-1 funding are routinely declined. (AI summary)
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[Page 1] RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026). THIS RESPONSE IS BEING SENT TO: The Senior Coroner, Jeremy Chipperfield for the Coroner Area County Durham and Darlington in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an investigation into the death of Patricia Mary Barnett.
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, provides this response within 56 days (plus any extension granted) of the date of the Report to Prevent Future Deaths.
2. DATE OF RESPONSE 1st June 2026
3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report are as follows: «PfdMattersOfConcern»
4. DETAILS OF ACTION TAKEN, how has the concern been addressed. [If no action is proposed please explain why here]. Below are the actions taken which are those that were in place at the time of PB fall.
a. Allocate staff to oversee the lounge area. Staff are allocated to observe communal areas to reduce the risk of falls by early intervention. This however is more challenging overnight as there are less staff in the service.
b. Consider a technological response (sensors). The service uses chair sensors for those at risk of falls, this measure serves to alert staff when a resident rises but cannot prevent a fall.
c. Apply for one-to-one support as required. PB was a known falls risk and a request for 1-1 funding to support the reduction of the falls risk, but this was declined, as many other requests for 1-1 funding for falls risks.
[Page 2]
5. DETAILS OF FURTHER ACTION PROPOSED What we will implement going forward is that residents who are at risk of falls will be the priority residents to support to bed, this will reduce the risk of high falls risk residents being unobserved in communal areas. This is dependent on the choice of the resident. We will continue to use assistive technology such a sensor mats and chair sensors to alert staff if a resident is standing. We will continue to request 1-1 funding to support those at risk of falls, but as stated these are routinely declined by the local authority.
6. SIGNATURE Operational Support Manager.
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, provides this response within 56 days (plus any extension granted) of the date of the Report to Prevent Future Deaths.
2. DATE OF RESPONSE 1st June 2026
3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report are as follows: «PfdMattersOfConcern»
4. DETAILS OF ACTION TAKEN, how has the concern been addressed. [If no action is proposed please explain why here]. Below are the actions taken which are those that were in place at the time of PB fall.
a. Allocate staff to oversee the lounge area. Staff are allocated to observe communal areas to reduce the risk of falls by early intervention. This however is more challenging overnight as there are less staff in the service.
b. Consider a technological response (sensors). The service uses chair sensors for those at risk of falls, this measure serves to alert staff when a resident rises but cannot prevent a fall.
c. Apply for one-to-one support as required. PB was a known falls risk and a request for 1-1 funding to support the reduction of the falls risk, but this was declined, as many other requests for 1-1 funding for falls risks.
[Page 2]
5. DETAILS OF FURTHER ACTION PROPOSED What we will implement going forward is that residents who are at risk of falls will be the priority residents to support to bed, this will reduce the risk of high falls risk residents being unobserved in communal areas. This is dependent on the choice of the resident. We will continue to use assistive technology such a sensor mats and chair sensors to alert staff if a resident is standing. We will continue to request 1-1 funding to support those at risk of falls, but as stated these are routinely declined by the local authority.
6. SIGNATURE Operational Support Manager.