Francis Leech

I am David REID, HM Senior Coroner, for the coroner area of Worcestershire.

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners Investigations) Regulations 2013.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary.

SUMMARY OF CORONER’S CONCERN (a) staff at Bowood Court Care Home, Redditch did not understand the importance of updating residents’ care plans and behavioural support plans; (b) management at the care home had not instituted a system of checking and ensuring those plans were updated; and (c) a subsequent internal investigation carried out by the care home failed to recognize the deficiencies in those plans, or to put in place measures to ensure that those deficiencies were not repeated.