Concerns raised 4 Failure to properly investigate and risk assess catastrophic injury and death incidents in social housing View source Lack of risk assessment of high-rise windows and their safety latches View source Absence of a formal procedure or policy for investigating and risk assessing catastrophic injury and death incidents View source Failure to consult the Building Safety Regulator about window safety risks View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Saffra Harriett Winn · 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
On 24 July 2022, Saffra Harriett Winn was found unconscious and not breathing on pavement between two high-rise blocks of flats after falling or jumping from a window of her flat. The report raised concerns that Sheffield City Council had not risk-assessed the windows or safety latches after two tenant fatalities, and lacked a formal process for investigating and assessing risks following catastrophic injuries or deaths in its social housing.
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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to properly investigate and risk assess catastrophic injury and death incidents in social housing
Wider context from the report “The inquest heard that there have been two fatalities by tenants falling from this type of window in high-rise buildings in a short period of time between July 2022 and December 2023. Notwithstanding these fatal events, Sheffield City Council has not yet completed any risk assessment of the windows or the safety latches on the windows. A Building Safety Regulator was put in post at the council in January 2023, some 11 months before the second fatality and 6 months after the first, and this person has not been consulted in relation to the safety or risk posed by the windows. I am concerned that this poses a risk of future death.
More generally, I am concerned by Sheffield City Council’s in action in relation to the investigation and assessment of risk following cases of catastrophic injury and death within their social housing stock. I am concerned that a failure to properly investigate and risk assess any incident of this nature , together with the absence of any formal procedure or policy for this process, poses a risk of future death. There is no evidence before the inquest which alleviates my concern in this respect, in fact the inquest was told that the Head of Housing Investment and Maintenance for the council was not aware of the fatal incidents above until his attendance was required at this 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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment of high-rise windows and their safety latches
Wider context from the report “The inquest heard that there have been two fatalities by tenants falling from this type of window in high-rise buildings in a short period of time between July 2022 and December 2023. Notwithstanding these fatal events, Sheffield City Council has not yet completed any risk assessment of the windows or the safety latches on the windows . A Building Safety Regulator was put in post at the council in January 2023, some 11 months before the second fatality and 6 months after the first, and this person has not been consulted in relation to the safety or risk posed by the windows. I am concerned that this poses a risk of future death.
More generally, I am concerned by Sheffield City Council’s in action in relation to the investigation and assessment of risk following cases of catastrophic injury and death within their social housing stock. I am concerned that a failure to properly investigate and risk assess any incident of this nature, together with the absence of any formal procedure or policy for this process, poses a risk of future death. There is no evidence before the inquest which alleviates my concern in this respect, in fact the inquest was told that the Head of Housing Investment and Maintenance for the council was not aware of the fatal incidents above until his attendance was required at this 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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Absence of a formal procedure or policy for investigating and risk assessing catastrophic injury and death incidents
Wider context from the report “The inquest heard that there have been two fatalities by tenants falling from this type of window in high-rise buildings in a short period of time between July 2022 and December 2023. Notwithstanding these fatal events, Sheffield City Council has not yet completed any risk assessment of the windows or the safety latches on the windows. A Building Safety Regulator was put in post at the council in January 2023, some 11 months before the second fatality and 6 months after the first, and this person has not been consulted in relation to the safety or risk posed by the windows. I am concerned that this poses a risk of future death.
More generally, I am concerned by Sheffield City Council’s in action in relation to the investigation and assessment of risk following cases of catastrophic injury and death within their social housing stock. I am concerned that a failure to properly investigate and risk assess any incident of this nature, together with the absence of any formal procedure or policy for this process , poses a risk of future death. There is no evidence before the inquest which alleviates my concern in this respect, in fact the inquest was told that the Head of Housing Investment and Maintenance for the council was not aware of the fatal incidents above until his attendance was required at this 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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to consult the Building Safety Regulator about window safety risks
Wider context from the report “The inquest heard that there have been two fatalities by tenants falling from this type of window in high-rise buildings in a short period of time between July 2022 and December 2023. Notwithstanding these fatal events, Sheffield City Council has not yet completed any risk assessment of the windows or the safety latches on the windows. A Building Safety Regulator was put in post at the council in January 2023, some 11 months before the second fatality and 6 months after the first, and this person has not been consulted in relation to the safety or risk posed by the windows . I am concerned that this poses a risk of future death.
More generally, I am concerned by Sheffield City Council’s in action in relation to the investigation and assessment of risk following cases of catastrophic injury and death within their social housing stock. I am concerned that a failure to properly investigate and risk assess any incident of this nature, together with the absence of any formal procedure or policy for this process, poses a risk of future death. There is no evidence before the inquest which alleviates my concern in this respect, in fact the inquest was told that the Head of Housing Investment and Maintenance for the council was not aware of the fatal incidents above until his attendance was required at this inquest.
” 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 Undertake a risk assessment of high-rise windows after receiving the independent expert’s report.
Verbatim wording from the response “The chartered building surveyor who has been instructed has expertise in structural and defect diagnosis, and safety, health and environment issues. The Council has asked the expert to advise on risk assessing the windows and the factors to be considered. The Council intends to undertake a risk assessment of the windows following receipt of the expert’s report. It is anticipated that this report will be received by SCC, no later than the 14th June 2024. The findings of this report and any subsequent recommendations will be shared with the Council’s Housing and Repairs Improvement Board which is Chaired by the Executive Director of Neighbourhood Services.” Source location Response from Sheffield City Council
Open published response
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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 Obtain an independent Chartered Surveyor’s review and report on high-rise windows and restrictors, including legal compliance and fixed-restrictor implications.
Verbatim wording from the response “However, the Council has instructed an independent Chartered Surveyor to undertake a review and prepare a report of the windows in high-rise Council blocks. The expert has been asked to comment on issues including:” Source location Response from Sheffield City Council
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 Establish a procedure and reporting framework for recording high-rise falls fatalities and near misses and identifying when window safety reports are required.
Verbatim wording from the response “SCC has also instigated a new procedure and reporting framework which will log all reported fatalities and near misses from falls from high rise council accommodation and guidance outlining when a safety report is required on the functionality of the windows and restrictors. This guidance is currently going through the appropriate approvals process and will again be in place by 14th June 2024. Thankfully I can report that there have been no further fatalities from falling from tower blocks since the incident in December 2023. This guidance will set out clear roles and responsibilities from the role of the Responsible Person, normally a Council Director, to who undertakes what function and when. It is also proposed that each fatality is reported to the Council’s Housing Policy Committee.” Source location Response from Sheffield City Council
Open published response
Concerns raised 4 Failure to pass updated information to third-party call-handling contractors View source Failure of one-person responder units to attend falls when assistance is required View source Failure to update call-handling information after significant changes View source Insufficient responder staffing and cover for falls View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Allan Herbert Shepard · 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
Allan Herbert Shepard, aged 89, fell at home on 8 February 2018 while being assisted out of his wheelchair and remained trapped in a hoist awaiting help. His breathing deteriorated, and he lost consciousness from positional asphyxiation before the ambulance attended; he died later that day in hospital. The concerns related to responder staffing and policies for single-person units, and to outdated information about Mr Shepard and his family situation held by the call-handling service.
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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to pass updated information to third-party call-handling contractors
Wider context from the report “(2) The information that had been provided to the call handling centre by City Wide Care Alarms about Mr Shepard and his family situation had not been updated since 2015. On this occasion Mr Shepard was being assisted by his son who himself had a visual impairment. Mr Shepard junior was struggling to see the difficulty his father was in. This is important information that may allow operators to prioritise calls and/or provide more complete information to the emergency services to allow them to accurately prioritise the call. Updated information about Mr Shepard was available to City Wide Care Alarms but had not been passed on to their third party call centre contractors. It would be helpful if the information could be updated when there is a significant change and City Wide Care Alarms is invited to consider how this can be done.
” 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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of one-person responder units to attend falls when assistance is required
Wider context from the report “(1) City Wide Care Alarm Service’s own guidance requires where there has been a fall a response should be provided within 30 minutes. During the time period when Mr Shepard was waiting for a response, there were two units available, However, one of the units was made up of only one person. The two person unit was engaged answering other calls in the 30 minutes following Mr Shepard’s alert. The one person responder unit was available to attend calls during this 30 minutes period but could attend a fall to provide assistance. Although the ambulance was contacted their response time was given as 4 hours. This 50% reduction in responders available to answer calls may risk further deaths when a person has suffered a fall. Therefore, City Wide Care Alarm Service is invited to consider its staffing levels and systems for providing cover. It is also invited to reconsider its policy regarding one person responder units when the injured person is already attended by someone else who may be able to assist.
” 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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to update call-handling information after significant changes
Wider context from the report “(2) The information that had been provided to the call handling centre by City Wide Care Alarms about Mr Shepard and his family situation had not been updated since 2015. On this occasion Mr Shepard was being assisted by his son who himself had a visual impairment. Mr Shepard junior was struggling to see the difficulty his father was in. This is important information that may allow operators to prioritise calls and/or provide more complete information to the emergency services to allow them to accurately prioritise the call. Updated information about Mr Shepard was available to City Wide Care Alarms but had not been passed on to their third party call centre contractors. It would be helpful if the information could be updated when there is a significant change and City Wide Care Alarms is invited to consider how this can be done.
” 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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient responder staffing and cover for falls
Wider context from the report “(1) City Wide Care Alarm Service’s own guidance requires where there has been a fall a response should be provided within 30 minutes. During the time period when Mr Shepard was waiting for a response, there were two units available, However, one of the units was made up of only one person. The two person unit was engaged answering other calls in the 30 minutes following Mr Shepard’s alert. The one person responder unit was available to attend calls during this 30 minutes period but could attend a fall to provide assistance. Although the ambulance was contacted their response time was given as 4 hours. This 50% reduction in responders available to answer calls may risk further deaths when a person has suffered a fall. Therefore, City Wide Care Alarm Service is invited to consider its staffing levels and systems for providing cover. It is also invited to reconsider its policy regarding one person responder units when the injured person is already attended by someone else who may be able to assist.
” Open source report
Concerns raised 1 Risk of pedestrians being misled by conflicting pedestrian signals when crossing the northbound lanes of the A61 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Leslie Bingham · 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
Mr Leslie Bingham was struck by a police vehicle while crossing the A61 Penistone Road at Owlerton Green on his way to a family celebration. The report identified a significant possibility that pedestrians could be misled by a green pedestrian light and miss a red light prohibiting them from crossing the northbound lanes.
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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Risk of pedestrians being misled by conflicting pedestrian signals when crossing the northbound lanes of the A61
Wider context from the report “The evidence showed that there was a significant possibility that a pedestrian approaching the A61 from Owlerton Green adjacent to the Pizza Hut may be misled by a green light intended for pedestrians crossing the mouth of Owlerton Green and thus miss a red light prohibiting them crossing the northbound lanes of the A61 .
I therefore make this report.
” Open source report
Concerns raised 9 Failure to adjust the relevant safety assessment after serious injury information View source Insufficient collation and sharing of potentially important incident information View source Deficient national guidelines for incident information collation and sharing View source Failure to accurately collect, share and categorise incident information View source Failure to inform the relevant road-management function of a serious incident View source Failure of location risk assessment to recognise risk and prioritise major works funding View source Failure to maintain tree trimming sufficient to preserve road lighting View source Failure to require sharing of damage-only incidents View source Failure to properly identify incident locations in shared information View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Sean Craig Salvin · 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
Sean Craig Salvin died on 30 December 2015 from severe injuries sustained when his car left a heavily flooded road at Woolley Wood Bottom, Sheffield. The report identified concerns about failures by authorities to collect, share and collate information about incidents and flooding, as well as concerns about risk assessment and the identification of the location's increasing risk.
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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to adjust the relevant safety assessment after serious injury information
Wider context from the report “d) ████████ had suffered unpleasant injuries including a fractures to his lower back. Although this became known to the South Yorkshire Police, no adjustment was made . Amey advised the court that they had not been made aware of this incident.
” 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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient collation and sharing of potentially important incident information
Wider context from the report “a) The evidence showed that there was insufficient system for the collation and sharing of information to assure that each of the authorities was aware of potentially important incidents . If national guidelines were being followed, as was stated, then the evidence suggests that those guidelines are themselves deficient.
” 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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Deficient national guidelines for incident information collation and sharing
Wider context from the report “a) The evidence showed that there was insufficient system for the collation and sharing of information to assure that each of the authorities was aware of potentially important incidents. If national guidelines were being followed, as was stated, then the evidence suggests that those guidelines are themselves deficient .
” 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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately collect, share and categorise incident information
Wider context from the report “c) Further, the system did not apparently require ‘damage only’ incidents to be shared. It is appreciated that the sharing of minor incidents could easily become burdensome but the case of ████████ (August 2015) which was recorded as ‘damage only’ was actually a serious matter indicating that greater care is needed in the collection/sharing of information and subsequent categorisation .
” 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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the relevant road-management function of a serious incident
Wider context from the report “d) ████████ had suffered unpleasant injuries including a fractures to his lower back. Although this became known to the South Yorkshire Police, no adjustment was made. Amey advised the court that they had not been made aware of this incident .
” 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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of location risk assessment to recognise risk and prioritise major works funding
Wider context from the report “e) The risk assessment of this location was also of concern to the inquest, both in respect of prioritisation of funding for major work and in terms of the recognition of the degree of risk . This was a location where traffic might be expected to be travelling comparatively quickly with the low hazard of trees immediately adjoining the carriageway. The emergence of a propensity to flood was a most important addition to the risk calculation .
” 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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain tree trimming sufficient to preserve road lighting
Wider context from the report “g) Witnesses reported the street lighting as ‘adequate’ and a site inspection did not suggest otherwise. However, the growth of trees and the development of leaves in Spring and Summer will inevitably reduce the lighting available on the road unless proper (and probably substantial) trimming takes place . The court was told that this is a recognised and regular maintenance issue but a concern would arise if this was reduced for any reason such as future budgetary constraints .
” 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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to require sharing of damage-only incidents
Wider context from the report “c) Further, the system did not apparently require ‘damage only’ incidents to be shared . It is appreciated that the sharing of minor incidents could easily become burdensome but the case of ████████ (August 2015) which was recorded as ‘damage only’ was actually a serious matter indicating that greater care is needed in the collection/sharing of information and subsequent categorisation.
” 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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to properly identify incident locations in shared information
Wider context from the report “b) In particular, such sharing of information as there was did not always fully or even properly identify the location concerned . The inquest showed that it was not difficult to identify that a number of incidents had occurred in the same place prior to the fatal collision.
” 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 Develop and share interagency protocols and strategies to improve the collation and sharing of safety information.
Verbatim wording from the response “Since receiving your Report the Council has been working collaboratively with the South Yorkshire Police, Yorkshire Water PLC and Amey Hallam PLC to address the issues you raised. There has been extensive dialogue, including a number of meetings, which have culminated in the Protocols and Strategies that are referred to in the supporting documentation, all of which have been shared with the other agencies involved.” Source location Sean-Salvin-Response
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 Introduce the new Highway Flooding Priority Rating System, making it operational by 30 June 2017.
Verbatim wording from the response “The Highway Flooding Priority Rating System (please see appendix C) is entirely new and will be operational by 30th June 2017.” Source location Sean-Salvin-Response
Open published response
Concerns raised 1 Failure to act on safeguarding referrals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Leesley · 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
Mrs Leesley died in Northern General Hospital on 25 April 2016 from septicaemia and a urinary tract infection. Evidence at the inquest showed that a safeguarding report made by the GP was not acted upon despite an automated acknowledgment, and it was unclear whether this resulted from human or IT error.
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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to act on safeguarding referrals
Wider context from the report “During the inquest, evidence showed the GP made a safeguarding report on 4.3.16, but for reasons unknown, despite there being an automated acknowledgment, the referral was not acted upon .
It was unclear whether this was a case of unanimous error or IT error.
” 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 Complete the ongoing investigation into the missing safeguarding referral, including the IT audit and Serious Incident review, and produce the resulting incident report.
Verbatim wording from the response “4. IT systems audit” Source location 2016-0442-Response-by-Sheffield-City-Council-1
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 Implement an email-journaling facility to retain audit logs and track emails sent, received, deleted and other mailbox actions.
Verbatim wording from the response “3.1.4 The IT systems operating in the Adult Access Team are designed to prevent emails, including those that contain safeguarding referrals, from being accidentally deleted. To completely delete an email, it would have to be deleted from the inbox folder and then separately deleted from the deleted folder; two distinct actions. The Local Authority is putting in place a Journal function integrated into the IT system that will make it easier to retrieve and track deleted emails. Journal function enables the Local Authority to track every action in a specified mailbox, In this case the Mailbox for the Adult Access Team.” Source location 2016-0442-Response-by-Sheffield-City-Council-1
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 Remind all Adult Access staff of email-handling procedures to reduce the risk of safeguarding referrals being deleted or left unactioned.
Verbatim wording from the response “3.2.5 However, to further reduce the risk of a report not being actioned, all staff working within Adult Access team have been reminded of the existing procedures and process for handling emails to further reduce the risk of emails being deleted or not actioned correctly.” Source location 2016-0442-Response-by-Sheffield-City-Council-1
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 Amend automated safeguarding-referral acknowledgements to instruct senders to confirm receipt if Adult Access does not respond within two working days.
Verbatim wording from the response “3.1.1 On 9th December 2016, the final day of the inquest, ████████, Advanced Practitioner in the Community Access Prevention Team, amended the wording of the automated response generated when a safeguarding report is received by the Adult Access Team.” Source location 2016-0442-Response-by-Sheffield-City-Council-1
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 GP surgery must make the request for the forensic report from its NHS mail provider.
Verbatim wording from the response “5.2 ████████ has requested a forensic report and audit log via the Accenture agency responsible for the IT System at the GP surgery used to send the email.” Source location 2016-0442-Response-by-Sheffield-City-Council-1
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 There is no evidence that the referral was not actioned because of human error, and the circumstances appear isolated.
Verbatim wording from the response “There is no available evidence to suggest that non-action was the result of human error either by action or omission on this occasion.” Source location 2016-0442-Response-by-Sheffield-City-Council-1
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 Existing email-handling procedures and staff reminders have adequately addressed and minimised the risk of received referrals being missed through human error.
Verbatim wording from the response “3.2.5 However, to further reduce the risk of a report not being actioned, all staff working within Adult Access team have been reminded of the existing procedures and process for handling emails to further reduce the risk of emails being deleted or not actioned correctly.” Source location 2016-0442-Response-by-Sheffield-City-Council-1
Open published response
Concerns raised 1 Lack of carer training for responding to similar situations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marjorie Nesbitt · 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 Nesbitt, who was bedbound and living alone with carers attending four times a day, died after a fan heater was turned up and left on overnight, making the room extremely hot. The inquest found that she died from hyperthermia in the presence of ischaemic heart disease and pulmonary emphysema, with old age and frailty as contributing factors. The principal concern was whether carers should receive training on managing similar situations involving heating and no overnight review.
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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of carer training for responding to similar situations
Wider context from the report “(1) It is accepted that the circumstances were unusual and none of the carers were likely to have been trained what to do in such a situation . Indeed, it is accepted that they were placed in a difficult position, not turning the heater up would lead to the client being cold during the night, turning it up with no one due in to review the situation led to an uncomfortable and ultimately fatal situation for Mrs Nesbitt.
(2) Nonetheless, it is difficult to say that this would be a completely unique situation and it is not impossible that other carers will be faced with similar situations in the future . What is a carer supposed to do in that situation? One supposes that the only potential remedy might be to include the circumstances of this case as a discussion in training of carers.
” 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 Recommend that recipient organisations use the documents as training tools and information to inform health and social care staff about relevant risks.
Verbatim wording from the response “Sheffield City Council is making a recommendation that the above parties use the documents as a training tool and to provide information which informs those working in health and social care professions of the risks which are related to the content of the case.” Source location 2016-0263-Response-by-Sheffield-City-Council
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 Prepare a case-study document and practical advice for carers and others with caring responsibilities.
Verbatim wording from the response “You noted a potential remedy was to include the circumstances of this case as a discussion in the training of carers. To facilitate these discussions documents have been prepared and are included with this letter for your information.” Source location 2016-0263-Response-by-Sheffield-City-Council
Open published response
Concerns raised 1 Failure to prevent easy access to the top of the perimeter wall View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ahmad Doumani Khan · 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
Ahmad Doumani Khan, aged 20, died from multiple injuries after falling from the top level of the Q Park car park in Sheffield on 3 May 2012. The report identified a concern that access to the car park perimeter wall was very easy and dangerous, allowing people to climb onto it quickly and easily.
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 Sheffield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent easy access to the top of the perimeter wall
Wider context from the report “(1) Access to the perimeter wall is very easy. There is the height issue (only about 3 feet), but also the fact that inside the wall is a crash/protective barrier for the parking of cars, which was described by the friend as being used by Mr. Khan as a ‘step’, up on to the wall. The concern is that any person, of almost any age, and certainly much younger than Mr. Khan, could quickly and easily gain access to the top of the perimeter, wall for any purpose. Such access is clearly dangerous.
” 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 Contact Q Park Ltd and its managing director to encourage possible alterations improving protection of the car park’s top-deck parapet.
Verbatim wording from the response “Nevertheless I have written to Q Park Ltd to suggest possible alterations to the building to try and prevent something like this happening again. Officers have also spoken to the Managing Director of Q Park, ████████ in a bid to persuade them to take action, although we cannot insist on this.” Source location 2014-0291-Response-by-Sheffield-City-Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Planning Service cannot formally require parapet alterations because there is no planning breach and the facility complies with Building Regulations.
Verbatim wording from the response “On receipt of the Coroner’s report last year my enforcement team established that there was no breach of planning control at the Q Park facility and that the building is also compliant with the Building Regulations. This means that there is no formal action that we can take in this case.” Source location 2014-0291-Response-by-Sheffield-City-Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations