Recurring concern

Unreliable management of resident bedroom-door status for safe observation

First to latest report 3 Apr 2020 — 10 Dec 2020

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
2

What this concern includes

Includes failures in the dedicated management of resident bedroom-door status where unclear requirements, inadequate communication or missing records prevent staff from knowing or maintaining whether a resident's bedroom door should be open or closed for safety.

What is not included
  • Excludes generic clinical observation, falls prevention or care-planning failures unless they directly concern the required status of a resident's bedroom door.
  • Excludes general door-security, access-control or fire-door deficiencies that do not concern resident bedroom-door status for safe observation.
  • Excludes failures of physical door design, door hardware or privacy arrangements where the reported unsafe condition is not uncertainty or unreliability about the required bedroom-door status.
  • Excludes routine bedroom-door preferences or privacy issues where no safety-related requirement or control is identified.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Sunderland

    AI-generated summary

    Edward Mallaby · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Edward Mallaby died after a boxed television fell onto him in his room at Alexandra View Care Home, causing injuries, bedbound status and pneumonia. Concerns included the handling and secure storage of potentially hazardous personal property, failure or absence of alerts when he was out of bed, unclear observation arrangements, and the lack of a rapid learning exercise or deadline for policy and training review.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of clarity about whether a resident’s room door should be open

    Wider context from the report

    “4. Although the deceased had a falls risk assessment, it was not clear whether he was subject to hourly or half hourly observations, or whether the door to his room was to be open or not. ”

    Source location

    Edward Mallaby · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Issue updated resident belongings, resident admission, and falls management policies across the Group, with staff read-and-sign confirmation and Alexandra View supervision sessions.

    Verbatim wording from the response

    “Please find enclosed updated policies in respect of:”

    Source location

    2020-0277-Response-from-Roseberry-Care-Centres-Redacted
    Page 1 · response
    Published 6 January 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Repeat Prevention and Management of Falls training for Alexandra View staff.

    Verbatim wording from the response

    “The staff at Alexandra View have also repeated their Prevention and Management of Falls training to refresh their knowledge; all staff successfully completed this by 7th January 2021.”

    Source location

    2020-0277-Response-from-Roseberry-Care-Centres-Redacted
    Page 2 · response
    Published 6 January 2021

    Open published response

  2. Black Country

    AI-generated summary

    Edna May Davenport · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Edna May Davenport, a resident of Oak Court House residential care home, sustained head injuries during an unwitnessed assault by another resident and died in hospital on 12 December 2019. The report raised concerns about the removal of her alarm without documented alternative arrangements, inadequate recording and monitoring of observations, insufficient risk assessment of the other resident, and delays in responding to signs of head injury and deterioration.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record resident bedroom-door status

    Wider context from the report

    “(3) I also heard in evidence that the deceased preferred to have her bedroom door left open but this did not form part of her care plan and there was no evidence as to when the door was in fact left open, or when it was closed, or indeed whether the door was open when the other resident was found in the deceased’s room; ”

    Source location

    Edna May Davenport · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026