6 Sep 2023 Sheila Rosamund JOHNSON · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 5 Failure to keep doors to unoccupied rooms locked View source Failure to keep night lights on in common places View source Inadequacy of periodic nightly observations View source Lack of signage for bell ringing View source Inadequacy of the generic falls prevention policy View source See 2 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 4
Action
Use an electronic care-planning system to record night checks and link them directly to residents’ care plans.
View source
Action
Personalise generic care-home policies, including the falls prevention and management policy.
View source
Action
Personalise generic care-home policies, including the falls prevention and management policy.
View source
Action
Use an electronic care-planning system to record two-hourly night checks and link them directly to residents’ care plans.
View source See 1 more action Respondent positions A position is what this recipient says about the concern when it does not describe a specific action. 8
Position
The comprehensive falls prevention policy is legally and operationally adequate, although generic policies will be personalised for the home.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Bedroom doors cannot remain locked at all times because residents must retain freedom to access their rooms; locking is limited to local safety decisions.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action. View source
Position
Continuous lighting in common areas, resident choice for bedroom lighting, and care-plan documentation are considered sufficient arrangements.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Two-hourly night checks, previously inspected records, and electronic recording are considered sufficient observation arrangements.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
The comprehensive falls prevention policy, supplied by a professional provider and accessible to staff, was considered sufficient despite its generic format.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Bedroom doors cannot generally remain locked because residents have the freedom to enter their rooms; locking is only a local safety decision.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
Common areas and corridors were lit continuously; bedroom lighting was individually chosen by residents or documented in care plans when required.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
Night checks were conducted every two hours, recorded separately or electronically, and regarded as standard practice accepted during regulatory inspections.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source See 7 more positions
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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.
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× 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 Phoenix Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to keep doors to unoccupied rooms locked
Wider context from the report “2.Doors to unoccupied rooms were unlocked when they should have been locked .
” 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 Phoenix Care Centre; that does not assign responsibility.
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 .
” 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 Phoenix Care Centre; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of periodic nightly observations
Wider context from the report “5.Inadequate periodic nightly observations recorded at inquest .
” 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 Phoenix Care Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of signage for bell ringing
Wider context from the report “4.No signage to bell ring in place .
” 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 Phoenix Care Centre; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of the generic falls prevention policy
Wider context from the report “1.An inadequate generic falls prevention policy appeared to be in place .
” Open source report
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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 Use an electronic care-planning system to record night checks and link them directly to residents’ care plans.
Verbatim wording from the response “5. Inadequate periodic nightly observations recorded at inquest
Our night checks are done every 2 hours and have always been done. We do not recall being asked about these records at the inquest. Care plans were submitted, but records of night checks are kept separate.” Source location Response from Phoenix Care Centre 2
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 Personalise generic care-home policies, including the falls prevention and management policy.
Verbatim wording from the response “Normally a Policy, when an update is sent to me, is forwarded to the Home. The Manager goes through it and personalises it for the Home. Depending on the policy, it generally requires the care home name added and small changes made where necessary.” Source location Response from Phoenix Care Centre 2
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 Personalise generic care-home policies, including the falls prevention and management policy.
Verbatim wording from the response “Normally a Policy, when an update is sent to me, is forwarded to the Home. The Manager goes through it and personalises it for the Home. Depending on the policy, it generally requires the care home name added and small changes made where necessary.” Source location Response from Phoenix Care Centre
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 Use an electronic care-planning system to record two-hourly night checks and link them directly to residents’ care plans.
Verbatim wording from the response “5. Inadequate periodic nightly observations recorded at inquest
Our night checks are done every 2 hours and have always been done. We do not recall being asked about these records at the inquest. Care plans were submitted, but records of night checks are kept separate.” Source location Response from Phoenix Care Centre
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 The comprehensive falls prevention policy is legally and operationally adequate, although generic policies will be personalised for the home.
Verbatim wording from the response “1. An inadequate generic falls prevention policy appeared to be in place
Our Policies are supplied by a professional company that takes into account latest legislations in terms of Legal, Health & Safety, CQC, Safeguarding, etc. They are specifically written for care homes. We use them as it ensures we are compliant with these different areas.” Source location Response from Phoenix Care Centre 2
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 Bedroom doors cannot remain locked at all times because residents must retain freedom to access their rooms; locking is limited to local safety decisions.
Verbatim wording from the response “2. Doors to unoccupied rooms were unlocked when they should have been locked
Bedroom doors in a care home cannot be kept locked at all times. Phoenix Care Centre is a Residential Home and most of the residents there go in and out of their rooms whenever they wish to. They have the choice and freedom to do so. We even ‘personalise’ doors with their names, photographs of either themselves or items they recognise/associate with.” Source location Response from Phoenix Care Centre 2
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 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
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 Two-hourly night checks, previously inspected records, and electronic recording are considered sufficient observation arrangements.
Verbatim wording from the response “5. Inadequate periodic nightly observations recorded at inquest
Our night checks are done every 2 hours and have always been done. We do not recall being asked about these records at the inquest. Care plans were submitted, but records of night checks are kept separate.” Source location Response from Phoenix Care Centre 2
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 The comprehensive falls prevention policy, supplied by a professional provider and accessible to staff, was considered sufficient despite its generic format.
Verbatim wording from the response “1. An inadequate generic falls prevention policy appeared to be in place
Our Policies are supplied by a professional company that takes into account latest legislations in terms of Legal, Health & Safety, CQC, Safeguarding, etc. They are specifically written for care homes. We use them as it ensures we are compliant with these different areas.” Source location Response from Phoenix Care Centre
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 Bedroom doors cannot generally remain locked because residents have the freedom to enter their rooms; locking is only a local safety decision.
Verbatim wording from the response “2. Doors to unoccupied rooms were unlocked when they should have been locked
Bedroom doors in a care home cannot be kept locked at all times. Phoenix Care Centre is a Residential Home and most of the residents there go in and out of their rooms whenever they wish to. They have the choice and freedom to do so. We even ‘personalise’ doors with their names, photographs of either themselves or items they recognise/associate with.” Source location Response from Phoenix Care Centre
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
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 Night checks were conducted every two hours, recorded separately or electronically, and regarded as standard practice accepted during regulatory inspections.
Verbatim wording from the response “5. Inadequate periodic nightly observations recorded at inquest
Our night checks are done every 2 hours and have always been done. We do not recall being asked about these records at the inquest. Care plans were submitted, but records of night checks are kept separate.” Source location Response from Phoenix Care Centre
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations