7 Mar 2022 Joyce May DENNIS · Prevention of Future Deaths report Surrey
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Concerns raised 11 Lack of liaison and overview across care staff View source Lack of care notes View source Failure to review care notes View source Inadequate training and understanding about sepsis in elderly people View source Failure to investigate care concerns View source Insufficient training and understanding of subtle signs of illness in elderly people View source Lack of continuous observation sufficient to enable prompt medical assistance View source Trivialization of symptoms by staff without appropriate medical qualification View source Failure to ask simple questions to elicit whether concern is needed View source Failure to maintain accurate records of designated doctor visits and requested patients View source Lack of a process for recording family concerns View source See 8 more concerns
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Joyce May DENNIS · 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
Joyce May Dennis, a resident of Roseacre Care Home, became unwell on 9 September 2019 and deteriorated over the following days before being admitted to hospital with sepsis and the onset of a heart attack. She died at 15.30 on 13 September 2019. The principal concerns were inadequate monitoring and record-keeping, failure to investigate or escalate worsening symptoms, insufficient staff training about illness and sepsis in older people, poor liaison, and failure to record family concerns.
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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 Roseland; that does not assign responsibility.
PFD Monitor interpretation Lack of liaison and overview across care staff
Wider context from the report “3. There was evidence of failure to ask Joyce simple questions to elicit whether concern was needed; trivialization of her symptoms by people who were not medically qualified to say that those symptoms were trivial; and a general lack of liaison with each other and overview such that in snapshot form it was possible to miss or to minimise the symptoms Joyce had over the course of a week and to make assumptions which then put Joyce at risk .
” 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 Roseland; that does not assign responsibility.
PFD Monitor interpretation Lack of care notes
Wider context from the report “1. There was a lack of continuous oversight, a lack of notes , a lack of review of those notes and no investigations at the Care Home. It has been underlined to me heavily throughout the proceedings that the care staff are not medically qualified. I accept that and would not expect them to be so in a residential care home setting. However, they had a duty of care for Joyce and that included keeping her under sufficient observation to allow for medical assistance to be called promptly as necessary.
” 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 Roseland; that does not assign responsibility.
PFD Monitor interpretation Failure to review care notes
Wider context from the report “1. There was a lack of continuous oversight, a lack of notes, a lack of review of those notes and no investigations at the Care Home. It has been underlined to me heavily throughout the proceedings that the care staff are not medically qualified. I accept that and would not expect them to be so in a residential care home setting. However, they had a duty of care for Joyce and that included keeping her under sufficient observation to allow for medical assistance to be called promptly as necessary.
” 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 Roseland; that does not assign responsibility.
PFD Monitor interpretation Inadequate training and understanding about sepsis in elderly people
Wider context from the report “6. The understanding and training about sepsis in elderly people was not adequate .
” 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 Roseland; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate care concerns
Wider context from the report “1. There was a lack of continuous oversight, a lack of notes, a lack of review of those notes and no investigations at the Care Home. It has been underlined to me heavily throughout the proceedings that the care staff are not medically qualified. I accept that and would not expect them to be so in a residential care home setting. However, they had a duty of care for Joyce and that included keeping her under sufficient observation to allow for medical assistance to be called promptly as necessary.
” 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 Roseland; that does not assign responsibility.
PFD Monitor interpretation Insufficient training and understanding of subtle signs of illness in elderly people
Wider context from the report “2. Although the staff were aware of their duties if someone was ill they did not appear to have sufficient training or understanding of the signs of illness in the elderly which can be more subtle .
” 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 Roseland; that does not assign responsibility.
PFD Monitor interpretation Lack of continuous observation sufficient to enable prompt medical assistance
Wider context from the report “1. There was a lack of continuous oversight , a lack of notes, a lack of review of those notes and no investigations at the Care Home. It has been underlined to me heavily throughout the proceedings that the care staff are not medically qualified. I accept that and would not expect them to be so in a residential care home setting. However, they had a duty of care for Joyce and that included keeping her under sufficient observation to allow for medical assistance to be called promptly as necessary .
” 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 Roseland; that does not assign responsibility.
PFD Monitor interpretation Trivialization of symptoms by staff without appropriate medical qualification
Wider context from the report “3. There was evidence of failure to ask Joyce simple questions to elicit whether concern was needed; trivialization of her symptoms by people who were not medically qualified to say that those symptoms were trivial ; and a general lack of liaison with each other and overview such that in snapshot form it was possible to miss or to minimise the symptoms Joyce had over the course of a week and to make assumptions which then put Joyce at risk.
” 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 Roseland; that does not assign responsibility.
PFD Monitor interpretation Failure to ask simple questions to elicit whether concern is needed
Wider context from the report “3. There was evidence of failure to ask Joyce simple questions to elicit whether concern was needed ; trivialization of her symptoms by people who were not medically qualified to say that those symptoms were trivial; and a general lack of liaison with each other and overview such that in snapshot form it was possible to miss or to minimise the symptoms Joyce had over the course of a week and to make assumptions which then put Joyce at risk.
” 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 Roseland; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate records of designated doctor visits and requested patients
Wider context from the report “5. There were no accurate notes of when the designated doctor was to visit or who the doctor was asked to see .
” 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 Roseland; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for recording family concerns
Wider context from the report “4. There was no recording of family concerns and no process in place to do so .
” 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