Cornwall and the Isles of Scilly Safeguarding Adults Board

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First report 8 Jan 2016•Latest report 12 Jan 2016

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Cornwall and the Isles of Scilly Safeguarding Adults Board linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Cornwall

    AI-generated summary

    Anne Shirley Scott · 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

    Anne Shirley Scott had an unwitnessed fall and was found at home on 29 August 2014. She was admitted to hospital with acute kidney injury secondary to rhabdomyolysis, but her renal function deteriorated and she died on 19 September 2014 after discharge for end-of-life care. The principal concern was that care providers using a Telehealth monitoring device lacked the training to understand its information and take appropriate action, including identifying a urinary tract infection linked to confusion and vulnerability to falls.

    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. The report was sent to Cornwall and the Isles of Scilly Safeguarding Adults Board; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of care-provider training to operate, interpret and respond to special health monitoring devices

    Wider context from the report

    “1. That special health monitoring devices are being used to monitor health conditions in patients who are receiving care in the community. However the care providers do not have the necessary training to be able to understand how the device operates, the information it provides and appropriate action to take, dependent on the information from the device, in conjunction with other observations. At the inquest we heard that this matter was referred to the Safeguarding Adults Board and some learning points had been identified for the care providers. In particular, it was known that Mrs Scott was prone to urinary tract infections and whilst suffering from these infections Mrs Scott was known to become confused. A special health monitoring device (Telehealth) was in place. The care provider failed to identify the urinary tract infection prior to admission. These were addressed in the Adult Safeguarding Board learning points. ████████ (Social Worker) and ████████ (Care Provider Representative) confirmed changes were being considered but could not confirm if recommendations were being implemented. Both the representative of the Safeguarding Adults Board and the care provider consider that a Regulation 28 report would assist in embedding the Safeguarding Adults Board recommendations which had countywide implications. ”
    Open source report

  2. Cornwall

    AI-generated summary

    Norman Dorn · 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

    Norman Dorn was found presumed dead in an armchair at a residential home after eating a jam sandwich, with food in his mouth. He was known to have swallowing problems, and staff did not remove the food or attempt resuscitation; the report also states that the GP and other emergency services did not attend in a timely manner. The concerns included whether care homes had adequate policies and staff training for recognising or confirming death and for resuscitation.

    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. The report was sent to Cornwall and the Isles of Scilly Safeguarding Adults Board; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of appropriate care-home resuscitation policies and staff preparation to preserve life

    Wider context from the report

    “2. That some care home in Cornwall may not have an appropriate resuscitation policy in place to ensure that all attempts have been made to preserve life (when appropriate). If such policies are in place that they are regularly updated and staff are made aware of them and given the appropriate training. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cornwall and the Isles of Scilly Safeguarding Adults Board; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of adequate care-home policies and staff preparation for recognising or arranging confirmation of death

    Wider context from the report

    “1. That some care homes in Cornwall may not have adequate policies in place for their residence to appropriately recognise or arrange confirmation of death (i.e. when to call Emergency Service and or GP to recognise death). If such policies are in place that they are regularly updated and the staff are made aware of them and given the appropriate training. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026