Roseland

Private and voluntary organisations · Residential care home

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First report 7 Mar 2022•Latest report 7 Mar 2022

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: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

Statements from Roseland linked to the concerns in each report. Select any concern, action or position to view the source wording.

7 Mar2022
Surrey
Concerns raised11
1. Lack of liaison and overview across care staff
2. Lack of care notes
3. Failure to review care notes
1. Inadequate training and understanding about sepsis in elderly people
2. Failure to investigate care concerns
3. Insufficient training and understanding of subtle signs of illness in elderly people
4. Lack of continuous observation sufficient to enable prompt medical assistance
5. Trivialization of symptoms by staff without appropriate medical qualification
6. Failure to ask simple questions to elicit whether concern is needed
7. Failure to maintain accurate records of designated doctor visits and requested patients
8. Lack of a process for recording family concerns
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

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.

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 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

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

Reports, concerns and published responses

Reports over time

Concerns raised11

Lack of liaison and overview across care staff

Lack of care notes

Failure to review care notes

Inadequate training and understanding about sepsis in elderly people

Failure to investigate care concerns

Insufficient training and understanding of subtle signs of illness in elderly people

Lack of continuous observation sufficient to enable prompt medical assistance

Trivialization of symptoms by staff without appropriate medical qualification

Failure to ask simple questions to elicit whether concern is needed

Failure to maintain accurate records of designated doctor visits and requested patients

Lack of a process for recording family concerns