13 Feb 2017 Roger Harold Tombs · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Failure to place fall sensor mats on a hard floor View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Roger Harold Tombs · 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
Roger Harold Tombs died at Queen Elizabeth Hospital on 4 May 2016 after being admitted following a fall at Sunrise Care Home. He had a history of learning disabilities and an increasing risk of falls; the medical cause of death included bronchopneumonia and severe traumatic brain injury. Concerns included the failure of fall sensor mats to sound an alert and the practice of placing them on top of crash mats, which may reduce their effectiveness.
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 Sunrise Senior Living Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to place fall sensor mats on a hard floor
Wider context from the report “2. The instructions for use of the sensor mats state they should be placed on a hard floor.
3. The investigating police officer from the public protection unit gave evidence that she was concerned that the crash mats below the sensor mats would reduce the effectiveness of the sensor mats and this could possibly be the reason the mat didn’t sound (there were other possible explanations).
4. The evidence was that Sunrise of Knowle is still placing sensor mats on top of crash mats.
5. No expert opinion has been sought on this practice but the evidence of the investigating police officer was that the managing director of the local distributors of the mats told her this was an unsafe practice in his view .
6. It is my opinion that there is a risk that the effectiveness of the sensor mats is being reduced by placing them on crash mats and if this is the case they may not sound when vulnerable residents are mobilising especially when there is a risk of falls, injury and potentially death.
” Open source report
×
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 Unable to describe measures implemented after 1 March 2017 because it will no longer manage the Home.
Verbatim wording from the response “It is expected that SSL will be leaving the Home and will be deregistered by CQC on 1 March 2017, with another provider coming in to manage the Home and who will be registered with CQC. SOK remains registered with the CQC.” Source location 2017-0027-Response-by-Sunrise-Senior-Living
Open published response
15 Dec 2014 RHYS TUDOR WILLIAMS · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 12 Failure to apply bed brakes when staff are not in the room View source Inaccessibility of archived files needed to provide relevant information to relatives View source Lack of training of carers providing immediate care View source Failure to properly assess required staffing levels View source Failure to ensure staff know to call an ambulance directly when required View source Failure to pass relevant care information to successor staff View source Allocation of additional cleaning and laundry duties to night staff View source Failure to ensure crash mats and sensor mats are provided on both sides of the bed View source Failure to allocate people to the correct type of care View source Failure to complete care notes contemporaneously with visits View source Failure to monitor and check completion of required e-learning View source Failure to ensure staff awareness of profile-bed positioning rules View source See 9 more concerns
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
RHYS TUDOR WILLIAMS · 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 3 March 2014, RHYS TUDOR WILLIAMS was put to bed at Sunrise Senior Living and was found deceased between his bed and the wall at 1.40 am. The report raised concerns about inadequate staff training, incorrect bed positioning, failure to apply bed brakes, insufficient staffing and communication, pre-completed care notes, and possible delays in calling an ambulance.
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 Sunrise Senior Living Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to apply bed brakes when staff are not in the room
Wider context from the report “5. The requirement for bed brakes to be properly applied when the staff members are not in the room should be an absolute requirement and this should be reinforced in writing to all staff.
” 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 Sunrise Senior Living Limited; that does not assign responsibility.
PFD Monitor interpretation Inaccessibility of archived files needed to provide relevant information to relatives
Wider context from the report “7. Following on from 6 above, the system for providing relevant information to the relatives was flawed as the necessary files were archived and inaccessible . Has this been changed or is it intended that it should be? This is relevant to future deaths, because it may hamper the ability to ensure that the patient is receiving optimum care in the most appropriate establishment.
” 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 Sunrise Senior Living Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of training of carers providing immediate care
Wider context from the report “1. There appeared to be a lack of training (in a number of areas) of the carers having immediate care of Dr Williams . I was told that they should all undertake e-learning but it was far from clear as to how (or whether) this was monitored and checked.
” 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 Sunrise Senior Living Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to properly assess required staffing levels
Wider context from the report “3. I was told about the way in which Care Establishments must now assess their clientele and based on that assessment, they should determine how many staff members are required at any time. I remain unconvinced that a proper assessment had taken place but in any event I was told that the night staff members had to perform additional tasks of cleaning and laundry. Has this assessment of the number of staff and the additional duties to be undertaken by them, been addressed?
” 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 Sunrise Senior Living Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff know to call an ambulance directly when required
Wider context from the report “9. Some members of staff were clearly under the impression that they should not call an ambulance but should contact the nurse on site who would then do so . This could lead to unacceptable delays in the attendance of potentially life-saving emergency services. Has this misapprehension been addressed?
” 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 Sunrise Senior Living Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to pass relevant care information to successor staff
Wider context from the report “6. There was an apparent failure by the staff (notably the managers who changed on a number of occasions) to pass relevant information to their successors , and the daughter of Dr Williams had to reiterate the same information several times. This led to a lack of confidence by the family of the deceased that his care needs were properly being made known to those having care of him.
” 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 Sunrise Senior Living Limited; that does not assign responsibility.
PFD Monitor interpretation Allocation of additional cleaning and laundry duties to night staff
Wider context from the report “3. I was told about the way in which Care Establishments must now assess their clientele and based on that assessment, they should determine how many staff members are required at any time. I remain unconvinced that a proper assessment had taken place but in any event I was told that the night staff members had to perform additional tasks of cleaning and laundry . Has this assessment of the number of staff and the additional duties to be undertaken by them, been addressed?
” 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 Sunrise Senior Living Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure crash mats and sensor mats are provided on both sides of the bed
Wider context from the report “2. Despite the assurances of the Managing Director, who was very frank and helpful in her evidence, I remained far from satisfied that all the staff members were aware of the rules relating to the positioning of the ‘profile beds’ which are on caster wheels. Because of this lack of certainty amongst the staff members, Dr Williams’ bed was placed, allegedly, against the wall when apparently this should not have been the case. Are all the staff members now clear as to the Rules relating to the positioning of the profile beds? Is there a rule about the need for crash mats and sensor mats on both sides of the bed ?
” 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 Sunrise Senior Living Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate people to the correct type of care
Wider context from the report “4. During the course of the evidence it became apparent that public money was being sent to Sunrise Senior Living for the provision of nursing care for Dr Williams. Whilst I accept that a nurse was present on site albeit in the other part of the Home, this was accepted by the Managing Director as not amounting to the provision of nursing care. The payment was apparently ‘credited’ against the account of Dr Williams, but I am concerned that as a result of this apparently flawed system, he was not in fact allocated to the correct type of care . Has this system now been reviewed and any change brought about?
” 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 Sunrise Senior Living Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to complete care notes contemporaneously with visits
Wider context from the report “8. Care notes were completed for the full period of the night shift of the 3rd to the 4th March 2014, at the beginning of that shift, i.e. before the visits had actually taken place . This was clearly unacceptable. Has anything been put in place to prevent this happening in the future?
” 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 Sunrise Senior Living Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor and check completion of required e-learning
Wider context from the report “1. There appeared to be a lack of training (in a number of areas) of the carers having immediate care of Dr Williams. I was told that they should all undertake e-learning but it was far from clear as to how (or whether) this was monitored and checked .
” 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 Sunrise Senior Living Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff awareness of profile-bed positioning rules
Wider context from the report “2. Despite the assurances of the Managing Director, who was very frank and helpful in her evidence, I remained far from satisfied that all the staff members were aware of the rules relating to the positioning of the ‘profile beds’ which are on caster wheels. Because of this lack of certainty amongst the staff members, Dr Williams’ bed was placed, allegedly, against the wall when apparently this should not have been the case. Are all the staff members now clear as to the Rules relating to the positioning of the profile beds? Is there a rule about the need for crash mats and sensor mats on both sides of the bed?
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations