“S are as follows: During the course of the inquest the evidence revealed matters giving…”

The coroner’s concerns

S are as follows: During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) The information regarding Mr Wells’ medical conditions and medication held by RedAssure/Worthing Homes was not complete. RedAssure were the providers of the telecare service to Mr Wells and were part of Worthing Homes. RedAssure had contracted Apello to answer out of hours calls. During the inquest I heard evidence that when a resident moves into Worthing Homes sheltered housing they are asked to provide medical information; as are any persons who happen to accompany them. I heard that updates are requested from the residents by sending out a form. Neither Worthing Homes nor RedAssure seek permission from the residents to obtain medical information from their GP or other third parties. I heard evidence that the staff at Worthing Homes had been aware of Mr Wells’ special needs and vulnerability but this did not appear on the resident information sheet; which provides the information accessed by Apello. Whilst I heard evidence that Worthing Homes are no longer providing telecare support they still provide the medical information recorded on their residents to telecare providers. Subsequent to the inquest Worthing Homes provided further information to assist with the preparation of this report. This confirmed that RedAssure no longer existed and that Worthing Homes, as a social housing provider, were not involved in providing care or medical assistance. They state that medical information gathered at the application stage is solely for the purpose of ascertaining the prospective resident’s suitability for a property. Worthing Homes provided a full version of a review record from 2015 clearly stating that Mr Wells had learning difficulties. In addition a GP letter provided to Worthing Homes in 2008 states that Mr Wells had a low IQ. Neither of these pieces of information were transferred on the front sheet of the record, which appears to have been the source of the information entered onto Carenet. As a result of the incomplete records and summary Appello & SECAMB were not provided with important and accurate information regarding Mr Wells. (2) The telephone numbers for the RedAssure responders are not contained within the Appello call handling system (Carenet). Under the contract between RedAssure and Appello the operator should have called a responder once he had spoken to SECAMB. The operator phoned telephone numbers from the ‘listed contacts’ screen and believed that this included a responder. It did not. The RedAssure responders’ contact details are accessed via a separate policy document that the operator needs to open. No link to these numbers is provided from Carenet nor are they listed in the ‘contacts’ section of Carenet. (3) There is no mechanism for the automatic flagging of risks related to particular medical conditions or medications within Carenet. I heard evidence that Appello operators are not medically trained and are employed to handle a wide variety of of calls. There is no system in place highlighting risk factors which might allow the operators to respond more appropriately to medical emergencies and ensure that they pass the most important information to the emergency services. (4) Under NHS Pathways triage system ambulance calls received from third party callers are handled in a different way from those received from persons present with a patient. The SECAMB SIR indentified that the receipt of a call from a third party was a contributory factor, partly as it required a first party call back. Mr Wells stated he was not able to talk to the ambulance service on the telephone. From the evidence before the inquest it was clear that the Appello operator was still connected to Mr Wells when in contact with SECAMB. However there was no way for the operator pass the call though therby allowing direct contact between Mr Wells and the SECAMB EMA. (5) An early exit from the NHS Pathways Module 0 occurs when a call is received from a third party. Subsequent unanswered calls direct to the patient do not necessarily lead to a clincal review of the triage decision. From the evidence heard at inquest it was established that the EMA would exit module 0 of NHS Pathways at an early stage when a call received from a third party. All subsequent actions are largely dependant on the EMA correctly identifying the clinical position of the patient and correctly triaging it despite the limited number of questions asked of the caller. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by February 03, 2020. I, the coroner, may extend the period.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2019-0485

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0