Recurring concern

Failure to assess room suitability and safety before placement

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First reported 4 Dec 2013•Latest report 5 Feb 2024

Definition

What this concern includes

Includes failures to assess whether a patient or resident is suitable for a particular room before placement, including physical room hazards, floor or location suitability, and risks affecting the person's ability to communicate needs or summon help in an emergency.

Not included

  • Excludes generic clinical, falls or safeguarding risk assessments where room placement is not the object of assessment.
  • Excludes assessments conducted only after placement unless they are part of a deficient pre-placement process.
  • Excludes general accommodation, building or room-maintenance defects where no failure to assess room suitability or placement safety is identified.
  • Excludes placement decisions involving hospitals, care settings or accommodation where the relevant room-specific safety assessment is not the shared concern.
Reports
5

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2013–2024

First to latest report issue date

Stated actions
1

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.

Cygnet Newton House1
Essex Partnership University NHS Foundation Trust1
Hellesdon Hospital1
MyMil Limited1
Norfolk and Norwich University Hospital1
Norfolk and Norwich University Hospitals NHS Foundation Trust1
Norfolk and Suffolk NHS Foundation Trust1
Norfolk County Council1
Scraptoft Court Care Home1
The Queen Elizabeth Hospital, King's Lynn1

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. Essex

    AI-generated summary

    Georgia Dehaney-Perkins · 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

    Georgia Dehaney-Perkins was found deceased on 6 September 2022 on Latton Common, Harlow, after a history of mental health difficulties, self-harm and suicidal ideation. The medical cause of death was recorded as combined alcohol and drug toxicity. Concerns included the suitability and safety of her ward bathroom, incomplete risk assessment and incident recording, insufficient documentation and communication about medication and alcohol risks, and a lack of action after family raised concerns about her leaving home with medication.

    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 risk assessment of room suitability for a patient with a self-harming history

    Wider context from the report

    “(1) On 28 August Ms Dehaney-Perkins was agitated and distressed on return to the ward from leave and had consumed alcohol that was known to increase her risk of self-harm. ████████. Staff found Ms Dehaney-Perkins and removed the ligature. a. Ms Dehaney-Perkins was admitted to a room with an assisted bathroom (this was not a requirement for her) with a fault in the anti-ligature safety mechanism meant that the safety feature could not be implemented. b. There was no risk assessment about the suitability of this room for Ms Dehaney-Perkins a patient with a self-harming history at the time of the admission. c. The fixed-point ligature was not appropriately updated in the risk assessment and was not discussed at a discharge planning meeting. d. The Trust Datix Report was incomplete ”

    Source location

    Georgia Dehaney-Perkins · Prevention of Future Deaths report
    Page 2 · 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

    Carry out room-suitability risk assessments on admission and obtain multidisciplinary information about self-harm history and associated risk factors.

    Verbatim wording from the response

    “Thorough risk assessments are being carried out using EPUT risk assessment tools including suitability of rooms for all patients on admission. There is collaboration with mental health professionals, including psychiatrists, psychologists, community mental health nurses, GP’s and social workers to gather comprehensive information regarding the patient’s history of self-harm and associated risk factors.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 14 February 2024

    Open published response

  2. Norfolk

    AI-generated summary

    Jeanine Maria HUGGINS · 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

    Jeanine Maria Huggins, who was being treated for diffuse large B-cell lymphoma, was admitted with neutropenic sepsis, dehydration and acute kidney injury and initially showed clinical improvement. She was found not breathing during the night of 9 May 2022 and could not be resuscitated; the inquest concluded that she died from natural causes, with coronary artery atheroma and lymphoma on treatment recorded as the medical cause of death. Concerns included the absence of a formal risk assessment for patients placed in side rooms, including assessment of their ability to use a call bell or suitable alternatives, and failures to escalate raised NEWS scores in accordance with guidance.

    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 pre-placement side-room risk assessment of patients’ ability to communicate their needs in an emergency

    Wider context from the report

    “1. There is no requirement for a risk assessment to be carried out before a patient is placed in a side room (other than for risk of falls), so as to identify if they will have any risks and difficulties associated with communicating their needs to staff in an emergency situation. ”

    Source location

    Jeanine Maria HUGGINS · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Blackpool and the Fylde

    AI-generated summary

    Dennis Peter Stark · 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

    Dennis Peter Stark, who was detained at a rehabilitation unit, was found unresponsive in his second-floor bedroom on 27 May 2014 and later died after developing pneumonia and hypoxic brain injury. The report raised concerns that the absence of a lift and the difficulty of removing a person of his size from the second floor could delay emergency treatment and pose a risk to future patients requiring urgent medical attention.

    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

    Insufficient assessment of residents’ size and emergency medical removal needs when allocating accommodation

    Wider context from the report

    “1. During the course of the Inquest I heard evidence from a Paramedic Reynolds who had been called to Regency House (now Newton House) which is a rehabilitation unit that cares for individuals with mental health issues, Mr Stark having previously been diagnosed as suffering from schizophrenia. He was an obese gentleman who weighed in excess of 30 stones, and he had been found unresponsive in his room. He was residing in a second floor room at the premises. The premises have no lift. The Paramedic indicated that after her arrival, there followed a period of time during which Mr Stark had no pulse and required Cardio Pulmonary Resuscitation. However, once a pulse was noted it then took the ambulance crew approximately twenty-two minutes to leave the scene. She clearly felt that the time it took the crew to leave the premises was contributed to by the absence of a lift in the premises and to the extent that she felt at least half of the amount of time it took to leave the scene could have been avoided had a lift been in place. In reality Mr Stark had to be transported with some difficulty from his room, down some steps, and out to the ambulance and then taken to hospital. It could not be established from the evidence whether that increased amount of time contributed to Mr Stark’s eventual demise but I am concerned that a risk of future deaths may arise should someone requiring urgent medical attention be accommodated on the second floor of Newton House whose physical status is such that safe removal of that person from the building may be compromised and leave paramedics in similar difficulties. Although evidence was provided by the Nursing staff that when this gentleman was mobile he was able to use steps at the premises to get around, it appeared to me that there had been insufficient thought given to the prospect of him requiring urgent medical attention and whether his size may hinder his removal, particularly in the event of an emergency. ”

    Source location

    Dennis Peter Stark · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Norfolk

    AI-generated summary

    ANN MARY WELLS · 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

    Ann Mary Wells, a resident of Julian Hospital, fell in her room on 21 November 2013 while attempting to access the wall beside her bed, sustaining a fractured pelvis and later dying on 28 December 2013. The concerns identified were the positioning of the light switch beside her bed and the absence of a risk assessment for placing her in that room.

    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 risk assessment for room placement

    Wider context from the report

    “(2) No risk assessment had been carried out with regard to Mrs Wells being placed in this particular room. ”

    Source location

    ANN MARY WELLS · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Leicester City and South Leicestershire

    AI-generated summary

    Marjorie Evelyne Keogh · 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

    Marjorie Evelyne Keogh, a resident of Scraptoft Court Residential Care Home, fell through a first-floor landing balustrade while transferring to breakfast on 6 March 2010 and died the following day from bilateral pneumonia and multiple injuries. Concerns included the assessment of her suitability for a first-floor room, staffing levels and the absence of a manager, inconsistent risk and manual-handling assessments, and the strength and compliance of staircase furniture.

    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 assessment of suitability for occupying a first-floor room

    Wider context from the report

    “(1) On the admission of Mrs Keogh and at subsequent reviews there did not appear to have been an assessment of her suitability to occupy a room on the first floor. Please confirm that such an assessment is now completed, and provide written evidence of such a requirement. ”

    Source location

    Marjorie Evelyne Keogh · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026