PFD report

RHYS TUDOR WILLIAMS · Prevention of Future Deaths report

Get email alerts

Request correction

Issued 15 Dec 2014•Manchester South

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: 12
Recipients: 1
Responses found: 1
Stated actions: 12

Recipients and published responses

Sunrise Senior Living LimitedNo response found

Source document

Full report text

This is the full text from the original published report.

Open published report

Investigation and inquest

On 7th March 2014 I commenced an investigation into the death of RHYS TUDOR WILLIAMS dob 29TH APRIL 1927. The investigation concluded on the 3RD DECEMBER 2014 and the conclusion was one of ACCIDENTAL DEATH AGGRAVATED BY NEGLECT. The medical cause of death was (1a) ISCHAEMIC HEART DISEASE AND ATRIAL FIBRILLATION. (1l) ALZHEIMER’S DISEASE.

Coroner’s concerns

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.

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?

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?

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?

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.

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.

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.

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?

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?

Concerns and recipient responses

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

Concerns raised12

Failure to apply bed brakes when staff are not in the room
Part of recurring concern: Unreliable bed-brake safety controls
Inaccessibility of archived files needed to provide relevant information to relatives
Lack of training of carers providing immediate care
Part of recurring concern: Inadequate training and competence assurance for carers providing care

Responses linked to these concerns

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

Actions described in response 10

Action
Communicate that the person discovering an incident must call emergency services when warranted, and embed this instruction in General Managers’ training for team members.
Stated by Sunrise Senior Living UKStated completed
Action
Complete a full review of care documentation to improve continuity of information when care plans are updated.
Stated by Sunrise Senior Living UKStated completed
Action
Contract with an external archiving organisation to strengthen storage and retrieval of residents’ historical documentation.
Stated by Sunrise Senior Living UKStated in progress

Action
Communicate the rule requiring crash mats and sensor pads on both sides of beds for residents at risk of falling, subject to risk-assessed exceptions.
Stated by Sunrise Senior Living UKStated completed
Action
Monitor mandatory manual-handling training compliance through weekly reports and escalate concerns to the Director of Operations.
Stated by Sunrise Senior Living UKStated completed
Action
Communicate expectations to all staff that repositioning documentation must be completed after each episode of care.
Stated by Sunrise Senior Living UKStated completed
Action
Monitor and report team training completion, giving managers access to compliance information for their teams.
Stated by Sunrise Senior Living UKStated completed
Action
Run a monthly companywide comparison of nursing hours and FNC residents and investigate identified disparities.
Stated by Sunrise Senior Living UKStated completed
Action
Incorporate bed placement, profiling-bed safety and brake-use training into mandatory manual-handling training for care and nursing staff.
Stated by Sunrise Senior Living UKStated completed
Action
Provide monthly FNC recipient information to Operations Directors, who verify with home managers that listed residents receive nursing care.
Stated by Sunrise Senior Living UKStated completed

Respondent positions 3

Position
Universal sensor and crash mats are unnecessary because fall-risk assessment determines when mats and sensors are required on both sides.
Stated by Sunrise Senior Living UKExisting arrangements considered sufficient

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions 2

1
Provide regional training-officer support and face-to-face training for complex cases involving bed placement against walls.
Stated by Sunrise Senior Living UKStated completed
2
Monitor bed locations monthly, investigate concerning patterns, support corrective action, and share results quarterly at the Health and Safety Meeting.
Stated by Sunrise Senior Living UKStated completed

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

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised12

Failure to apply bed brakes when staff are not in the room

Inaccessibility of archived files needed to provide relevant information to relatives

Lack of training of carers providing immediate care

Failure to properly assess required staffing levels

Failure to ensure staff know to call an ambulance directly when required

Failure to pass relevant care information to successor staff

Allocation of additional cleaning and laundry duties to night staff

Failure to ensure crash mats and sensor mats are provided on both sides of the bed

Failure to allocate people to the correct type of care

Failure to complete care notes contemporaneously with visits

Failure to monitor and check completion of required e-learning

Failure to ensure staff awareness of profile-bed positioning rules

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.10

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

Actions described in response 10

Respondent positions 3

Recipient-stated actions 2