Rachel Johnston PFD Hearing

I was in court this morning for the resumption of Rachel Johnston’s inquest. It was part heard as one of the witnesses suffered a bereavement and it was agreed that it would be resumed to hear remaining evidence which spoke to the Coroner’s responsibility to issue a Prevention of Future Deaths report if he had outstanding concerns. At the end of the last hearing (you can find all my coverage of it here) the Coroner found neglect contributed to Rachel’s death. He specifically mentioned the nursing staff who failed to carry out adequate physiological observations, and failed to seek emergency assistance.

The focus of today’s hearing was very much whether others remained at risk of the same poor care that led to Rachel’s death. I think counsel for the care provider, Mr Mark Ley-Morgan, said more today than in the whole of the rest of the hearing combined. He impressed upon the Coroner the many changes that have been made since Rachel’s death.

The hearing today heard from Jane Colbourn, the registered manager at Pirton Grange Nursing Home, at the time of Rachel’s death and since and we also heard from Pasqueline Gill, Quality Assurance Manager for Holmleigh Care Homes Limited, who own Pirton Grange.

Jane Colbourn is registered with CQC as the Registered Manager for Pirton Grange, and held that role when Rachel died. Being registered manager comes with responsibilities including:

Registered managers, commonly the lead individual in learning disability settings, have a pivotal leadership role. Strong leadership is fundamental to the provision of high quality care. To be effective, leadership must be rooted in strong values, and based on a clear, shared understanding that it involves accountability for whatever is done in the name of care.


The registered manager has a variety of responsibilities under Regulations 21, 22 and 23 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 in relation to staff employed for the purposes of carrying on the regulated activity. Responsibilities include ensuring that the staff have the relevant qualifications, skills, experience and training to carry out the role. Staff in health and adult social care settings should be aware that managers have these responsibilities. They also include appropriate induction, relevant training, including refresher training, support that might include the use of mentoring/coaching arrangements, supervision and opportunities for staff to reflect on practice in an honest and open manner.

Jane Colbourn described in detail six policies that had been developed as a result of ‘lessons learned’ from Rachel’s death, the LEDER review that followed and the internal investigation, one of which was a ‘deteriorating patient’ policy. The Coroner questioned how the Court could be assured that these policies would be followed:

It might be said the matters covered in that policy are a matter of standard nursing practice anyway. What assurances can you give that staff, nursing staff in particular who work at Pirton Grange, are following that policy and have their attention drawn to that policy, rather than assuming this is standard nursing practice anyway?

He was clearly persuaded by the evidence offered in response by Ms Colbourn and Ms Gill, because he decided a PFD was not required in this regard given changes already made. Jane Colbourn responded:

That policy is part of six introduced after Rachel’s death. They are now displayed, they’re not only in the policy file, but also in the clinical office. They are specifically part of the nurses’ induction, although they have to read all the policies. They specifically are drawn more to those by the Clinical Manager. They have quarterly questionnaires sent out specifically on these six policies, where they’re asked to keep afresh of those policies and their competencies on those policies.

There was more discussion about training provided, to both Pirton Grange’s nurses and agency nurses, supervision provided, and steps taken to ensure all agencies were aware of the requirements for their staff if working at Pirton Grange.

Pasqueline Gill explained how Pirton Grange had only fallen into her portfolio in October 2020 as a result of the inquest. The Coroner pointed out the inquest had not taken place at that point but she explained that Dr Danbury’s report (the court appointed expert to the inquest) had been so damning in its criticism of the care provided by the nurses that it had been agreed that she’d start quality assuring Pirton Grange.

I was left with questions myself about how new policies were going to make a difference given, as Ms Gumbel QC pointed out in court, one of the nurses answered on oath that she knew her care was sub standard regardless of policies because it was basic nursing care she failed to provide.

MsG: They were working for you and continued to working for you after Rachel’s death. Did you think that was appropriate and other residents were put at risk from those nurses?

JC: We just tightened up the systems

MsG: Two nurses on your unit, you knew from your own questioning of them, who’d ignored basic nursing care; what did you do about that? Sadly Rachel died but there were other patients who could be at similar risk if those nurses continued to work for you.

JC: We bought in the policies and they knew to follow policies.

MsG: I asked Nurse George did it make a difference now there is a protocol, she said ‘protocol is common sense I knew to do those things as a qualified nurse’ so putting policy in place wasn’t going to make a difference if they were ignoring basic medical care would it?

JC: No

MsG: Did you think it was misconduct on behalf of those nurses who didn’t provide basic medical care?

JC: I find that very difficult to answer

MsG: Are you familiar with NMC guidance on misconduct?

JC: No

We heard that the Registered Manager did not consider other residents were at risk, in fact she went further in one answer suggesting these nurses posed less of a risk to other residents, than an agency nurse who didn’t know them.

This position held by Jane Colbourn, despite accepting that the nurse’s behaviour towards Rachel amounted to gross misconduct, in their failure to provide basic care, seek assistance and make records:

MsG: So if you accept the conduct of these nurses were misconduct why didn’t you first of all tell the agency you weren’t prepared to have them working in Pirton Grange any longer?

JC: At the time I’d say, although what’s happened has happened, they were consistent nurses who knew those residents well. It’s better to have those nurses than to have nurses that don’t know the other 34 residents at all.

This wasn’t really explored in any great detail by the Coroner. I desperately wanted someone to dig into why Pirton Grange needed to use agency nurses in the first place. During Rachel’s inquest we heard how they had been regularly used before and since her death. I’d have liked to understand more about why agency staff were required, and why they couldn’t recruit and retain their own staff.

It did seem quite a remarkable claim that the remaining residents were not at risk from two qualified nurses who failed to provide basic care. Ms Colbourn, let’s not forget, the Registered Manager of the service, appeared to suggest that the reason she took no disciplinary action against the agency staff, or let them go, was because there were no policies in place that they failed to follow – which of course, given the responsibilities of the registered manager listed in the CQC document quoted above, was her own responsibility.

So Ms Colbourn failed to ensure adequate and appropriate policies were in place prior to Rachel’s death. She then conducted an internal investigation following Rachel’s death, heard about failures in basic medical care and did nothing to mitigate risks faced by other residents.

The Court heard that the two nurses, Sheeba George and Gill Bennett had eventually been referred to the Nursing and Midwifery Council, their professional regulator, on 23 February. I find this astounding. Rachel died in November 2018.

After sitting through Rachel’s inquest I publicly stated my intention to refer the two nurses myself to the NMC over the weekend that followed. Early the next week I spoke to a member of NMC staff who assured me that it would be drawn to the attention of their monitoring team. They anticipated a referral might come via the Coroner, but it seems outrageous to me that neither Pirton Grange, the nurses’ agency employer or the registered manager Ms Colbourn, had taken any action themselves in the intervening 2+ years. The Coroner quizzed Ms Gill, the Quality Assurance Manager on this:

Coroner: I think I’m right in saying the two nurses concerned were only recently referred to the Nursing and Midwifery Council is that right?

PG: Yes

C: How recently?

PG: On the 23rd February from Holmleigh Pirton’s perspective

C: Why not before?

PG: I believe contact was made on 15th February regarding referral and prior to this it was believed it was going to be the responsibility of the employment agency, or was also possibly the NHS as one of the nurses actually worked for the NHS. As far as I’m aware CQC informed us we should go ahead and make that referral.

C: You’ve heard questions asked of Jane Colbourn, there was serious concerns about the conduct of these nurses. Why weren’t they referred by Pirton Grange?

PG: I cant answer that I’m afraid, I don’t know why that wasn’t done. We’ve all got a clearer understanding of NMC now, we understand referral can be made by any party. At that time I cant answer why they didn’t do it, I’m sorry.

C: Can you answer why the nurses were not stopped from working at Pirton Grange after Pirton Grange’s own internal investigation?

PG: The only way I could answer would be an opinion, I can’t answer why they kept them employed and continued using them.

As an aside, when Ms Gumbel asked questions of Ms Gill we heard about another failing of the Registered Manager, Ms Colbourn:

MsG: Do you know if anyone from your organisation who’d taken over sent any kind of apology to the family in relation to Rachel’s death?

PG: I’m sorry I’m not aware of that

MsG: Is there any policy about a death in one of your homes, for example who should make contact with the family and apologise and offer commiserations to them and so on?

PG: Yes, the registered manager would normally do a direct apology and as a provider we’d look to send out letter of condolences.

MsG: So if Rachel’s mother has not received anything what would be the explanation for that?

PG: I cant give an explanation, I can only apologise on behalf of Holmleigh Care because it should have happened.

I found Ms Gill to be a very straight forward witness, she didn’t appear to fudge her answers or try and make excuses for what are clearly failings. Sadly Coroner’s are not concerned with how bereaved families are treated, so this was not something that received further attention.

After all evidence was heard Ms Gumbel and Mr Ley Morgan were invited to make submissions to the Coroner. During submissions a conversation about other investigations ensued. Ms Gumbel made clear that as far as the family were aware there had not been an investigation conducted by the Care Quality Commission and there should have been a notification following Rachel’s death.

Mr Ley Morgan was similarly unaware of whether a notification had been made about Rachel’s ‘sad’ death (as an aside I honestly don’t think counsel at an inquest need to precede the word death with sad each time, it almost appears glib).

At this point, Carl Ingles, a CQC Inspector who had been observing Rachel’s inquest was put on the spot by the Coroner and asked if he could confirm the position. I had no video so was unable to see but he appeared rather flustered about finding the right backdrop for the court, but the Coroner reassured him it was not important given the unconventional request. He was not put under oath and explained in general terms the process.

He explained that there was a ‘process ongoing with regards to Pirton Grange’. He explained they look to see whether there is a Regulation 12 breach, which relates to provision of safe care:

CI: …we look at, weigh up, the information and evidence to look at whether or not there is a breach by the registered person, registered manager or registered provider or both, in relation to this. Which may then proceed on through our process to look at whether there is anything criminal to consider.

Obviously Mr Ingles was at pains to point out he was talking in general terms and couldn’t openly share information specific to this case as its an ongoing process. He explained that CQC are usually made aware through a death notification system.

Coroner: So am I right in thinking Mr Ingles it is quite common for the CQC to await outcome of inquest proceedings before deciding where to go from there?

CI: yes, it is. With regards to that information absolutely it is, part of our process, with the findings of inquests and we don’t routinely, I don’t know why, we don’t routinely attend inquests, we should attend more, I think its an incredibly important process for us as inspectors to attend. The information that we gather from that and information that we may well be sent following the inquest, will help formulate our thinking as the regulator as to our next steps and how we proceed with this.

I couldn’t agree with Mr Ingles more, about the need for CQC Inspectors to attend inquests. For now the Coroner will issue a Prevention of Future Death report:

Coroner: In my findings and conclusions I identified gross failings by nursing staff at Pirton Grange which I found contributed to Rachel’s death… failure to carry out adequate physiological observations and failure to seek medical attention for her.

We heard extensive evidence from Jane Colbourn, the Registered Manager at Pirton Grange about Pirton Grange’s own investigation and what measures have been taken as a result. We were taken through a number of new and revised policies now in force and heard how they’re implemented, training is now provided to Pirton Grange nursing staff in relation to those policies. The fact Pirton Grange had written to all agencies who provide nursing staff setting out training they are required to have to work at Pirton Grange and how all nurses’s training is recorded and audited. I am satisfied that sufficient measures have been taken by Pirton Grange in that regard that I would not need to make a Prevention of Future Death report specifically about those policies.

However, I was surprised to learn only recently that the two nurses concerned have never been reported to their regulatory body, the Nursing and Midwifery Council. In fact it appears to me there has never been a formal internal disciplinary procedure put in place for either of those nurses. It would seem for a period of time those nurses were able to carry on working at Pirton Grange following Rachel’s death. I’m told that issue would come under Pirton Grange’s own internal disciplinary policy, but I’m told there’s no formal policy or procedure where a nurse is found not to follow another policy in place. In fact Jane Colbourn seemed to be unaware even now what her obligations as care home manager is in reporting nurses whose conduct may be similar to nurses referred to already.

In the circumstances it seems concerning those nurses were not reported to NMC until February this year, over two years since Rachel’s death. Furthermore I’m not satisfied there are sufficiently robust procedures in place, where grave concerns about nurses’ conduct that disciplinary procedure is in place, so if necessary those nurses can be suspended while investigation takes place, and may be suspended permanently if home’s own procedures finds they committed misconduct.

In the circumstances I will be making a Prevention of Future Death report to the appropriate person at Pirton Grange requiring that they satisfy me what steps they propose to take to ensure such a procedure or policy is in place, to ensure appropriate disciplinary action, and if necessary suspension, of member of staff where there are actions they consider put others at risk.

I’ll try to keep you posted on whether CQC decide to take any action against Pirton Grange, or Jane Colbourn, the Registered Manager, or both.

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