PFD report

Patrick Kelly · Prevention of Future Deaths report

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Issued 17 Apr 2019•South Yorkshire (Western)

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Lack of adequate policies for dealing with missed dental appointments
  2. Failure to place adequate importance on residents' dental hygiene
  3. Lack of adequate policies for identifying when dental appointments may be required
    Part of recurring concern: Failure to ensure timely required dental care for care-home residents
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of adequate policies for dealing with missed dental appointments

Wider context from the report

“b) Roseberry Care Centres do not have adequate policies in place to deal with missed dental appointments and the identification of when dental appointments may be required. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to place adequate importance on residents' dental hygiene

Wider context from the report

“a) Roseberry Care Centres do not place adequate weight on the importance of dental hygiene and the provision of dental services to their residents. This has potentially resulted in the worsening of a dental abscess in one case. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of adequate policies for identifying when dental appointments may be required

Wider context from the report

“b) Roseberry Care Centres do not have adequate policies in place to deal with missed dental appointments and the identification of when dental appointments may be required. ”

Is this part of a recurring concern?

Yes — Failure to ensure timely required dental care for care-home residents.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to place adequate importance on the provision of dental services to residents

Wider context from the report

“a) Roseberry Care Centres do not place adequate weight on the importance of dental hygiene and the provision of dental services to their residents. This has potentially resulted in the worsening of a dental abscess in one case. ”

Is this part of a recurring concern?

Yes — Failure to ensure timely required dental care for care-home residents.

Open source report
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026