Recurring concern

Failure to maintain adequate lighting in occupied premises

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First reported 1 May 2020•Latest report 6 Sep 2023

Definition

What this concern includes

Includes failures of fixed lighting or required night lighting in occupied premises, including lounges, communal areas and comparable indoor or semi-enclosed spaces, where inadequate illumination can impair safe movement or recognition of hazards.

Not included

  • Excludes public-road and street-lighting systems, which are covered by distinct road-lighting concerns.
  • Excludes lighting deficiencies unrelated to safe visibility, such as decorative or aesthetic shortcomings without a safety consequence.
  • Excludes failures of emergency-egress lighting or specialist clinical examination lighting unless the assertion specifically concerns general safe visibility in occupied premises.
  • Excludes generic environmental, staffing or maintenance deficiencies where inadequate lighting is not itself the unsafe condition.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2020–2023

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Phoenix Care Centre1
Tui UK Limited1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Lincolnshire

    AI-generated summary

    Sheila Rosamund JOHNSON · 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

    Sheila Rosamund JOHNSON died at Butterfly Hospice on 14 February 2021 after an unwitnessed fall at her care home caused multiple rib fractures and fatal injuries. Concerns included an inadequate generic falls prevention policy, unlocked doors to unoccupied rooms, an unlit night light in common areas, no bell-ringing signage, and inadequate records of nightly observations.

    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 keep night lights on in common places

    Wider context from the report

    “3.Night light in common places not on. ”

    Source location

    Sheila Rosamund JOHNSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Continuous lighting in common areas, resident choice for bedroom lighting, and care-plan documentation are considered sufficient arrangements.

    Verbatim wording from the response

    “3. Night light in common places not on No idea as to how this has been brought up. All common areas, particularly corridors, have lights on 24/7. Bedroom lights are not always kept on – the decision for that is usually up to the resident as most of them do have the capacity to make that choice.”

    Source location

    Response from Phoenix Care Centre 2
    Page 1 · response
    Published 14 September 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Common areas and corridors were lit continuously; bedroom lighting was individually chosen by residents or documented in care plans when required.

    Verbatim wording from the response

    “3. Night light in common places not on No idea as to how this has been brought up. All common areas, particularly corridors, have lights on 24/7. Bedroom lights are not always kept on – the decision for that is usually up to the resident as most of them do have the capacity to make that choice.”

    Source location

    Response from Phoenix Care Centre
    Page 1 · response
    Published 14 September 2023

    Open published response

  2. County Durham and Darlington

    AI-generated summary

    Barrie Crawford COPELAND · 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

    Barrie Crawford Copeland fell down steps in the Broadway Show Lounge aboard the Marella Discovery on 23 August 2018 while looking for a seat, suffering a head injury that ultimately led to his death on 21 September 2018. Concerns were raised that carpet-covered steps and inadequate lighting made the change in floor level difficult to recognise, particularly for infirm people or those with poor eyesight, and that there was no evidence the scene had been examined by TUI.

    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 provide fully lit lounge lighting

    Wider context from the report

    “During the course of the evidence heard at the inquest, a witness described the step/s Mr COPELAND fell on were covered in carpet so as to make them difficult to recognise them as steps, and difficult to differentiate the change in the floor level at the venue. The lighting in the lounge can be altered and were not at the time of the accident fully lit. The step/s therefore could be the cause of future accidents. This is of particularly relevance to the infirm and/or those persons with poor eyesight. ”

    Source location

    Barrie Crawford COPELAND · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026