PFD report

Sheila Rosamund JOHNSON · Prevention of Future Deaths report

Get email alerts

Request correction

Issued 6 Sep 2023•Lincolnshire

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: 5
Recipients: 1
Responses found: 1
Stated actions: 4

Recipients and published responses

Phoenix Care CentreResponse found

Source document

Full report text

This is the full text from the original published report.

Open published report

Investigation and inquest

On 19 February 2021 I commenced an investigation into the death of Sheila Rosamund JOHNSON aged 91. The investigation concluded at the end of the inquest on 15 November 2022. The conclusion of the inquest was that:

The deceased died on 14th February 2021 at Butterfly Hospice, Rowan Way, Boston after being transferred there from hospital following an unwitnessed fall at her care home resulting in fatal injuries.

Circumstances of the death

Reported to the coroner by ████████ (Staff Nurse Butterfly Hospice) - Daughter wishing for the coroner to be involved as she believes her mothers death was the consequence of a fall at the care facility.
Following fall admitted to Pilgrim Hospital transferred to Hospice. Expected death at the hospice, was admitted on 11-02-2021 I have spoken to the coroners officer ████████.
on 14022021

Contacted Sidings Medical Centre for patient history.

Contacted NOK (daughter ████████ - via husband ████████ ) who explained that the deceased had been living in Phoenix Care Home for about a year and is believed to have suffered a fall there on 03/02/2021 where she was transferred to PHB with suspected multiple rib fractures and a punctured lung. Due to her age there was nothing other than palliative care and she was subsequently transferred from PHB to Butterfly Hospice where she died on 14/02/2021.

PM examination carried out by ████████ 17/02/2021

Contacted ████████ (manager - Phoenix Care Centre) who explained the fall occurred on 03/02/2021 at approx. 20.22hrs. She explained that Sheila suffered from advanced dementia and liked to 'walk with a purpose' and was allowed to wander around the building, she was not described as a frail lady with more of a substantial frame to her. ████████ believes she was on two types of medication used for patients with bone issues to build their bone density but can't remember the names of the medication
On the evening of the fall she had gone into a neighbours bedroom while the resident was elsewhere in the building, the room was dark at the time and staff herd her cry out. On entering the room they found her flat on her back on the floor but on top of the bed duvet that had been pulled off the bed. The bed in this room was described as a 'Profiling Bed' they are designed with a taller base board and also have a metal bar above the base board, ████████ thought it was possible for her to have fallen onto the base of the bed.
On arrival there were no obvious signs of injury to Sheila however she was clearly in pain so the team called 999 for assistance before moving her from the floor. On the arrival of paramedics she was raised to a chair by the paramedics and still in obvious pain so conveyed to Pilgrim Hospital.

PM examination carried out by ████████ who confirmed cause of death related to multiple rib fractures.

Concerns and recipient responses

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

Concerns raised5

Failure to keep doors to unoccupied rooms locked
Failure to keep night lights on in common places
Part of recurring concern: Failure to maintain adequate lighting in occupied premises
Inadequacy of periodic nightly observations
Part of recurring concern: Failure to carry out required overnight checks

Responses linked to these concerns

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

Actions described in response 4

Action
Use an electronic care-planning system to record night checks and link them directly to residents’ care plans.
Stated by Phoenix Care CentreStated completed
Action
Personalise generic care-home policies, including the falls prevention and management policy.
Stated by Phoenix Care CentreStated planned
Action
Personalise generic care-home policies, including the falls prevention and management policy.
Stated by Phoenix Care CentreStated planned

Respondent positions 8

Position
The comprehensive falls prevention policy is legally and operationally adequate, although generic policies will be personalised for the home.
Stated by Phoenix Care CentreExisting arrangements considered sufficient

Position
Bedroom doors cannot remain locked at all times because residents must retain freedom to access their rooms; locking is limited to local safety decisions.
Stated by Phoenix Care CentreUnable to act
Position
Continuous lighting in common areas, resident choice for bedroom lighting, and care-plan documentation are considered sufficient arrangements.
Stated by Phoenix Care CentreExisting arrangements considered sufficient
Position
Two-hourly night checks, previously inspected records, and electronic recording are considered sufficient observation arrangements.
Stated by Phoenix Care CentreExisting arrangements considered sufficient
Position
The comprehensive falls prevention policy, supplied by a professional provider and accessible to staff, was considered sufficient despite its generic format.
Stated by Phoenix Care CentreExisting arrangements considered sufficient
Position
Bedroom doors cannot generally remain locked because residents have the freedom to enter their rooms; locking is only a local safety decision.
Stated by Phoenix Care CentreDisputes the concern
Position
Common areas and corridors were lit continuously; bedroom lighting was individually chosen by residents or documented in care plans when required.
Stated by Phoenix Care CentreDisputes the concern
Position
Night checks were conducted every two hours, recorded separately or electronically, and regarded as standard practice accepted during regulatory inspections.
Stated by Phoenix Care CentreExisting 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 positions 1

1
A 24-hour watch was not considered necessary because walking freedom was medically advised and staff regularly engaged with the resident.
Stated by Phoenix Care CentreExisting arrangements considered sufficient

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 raised5

Failure to keep doors to unoccupied rooms locked

Failure to keep night lights on in common places

Inadequacy of periodic nightly observations

Lack of signage for bell ringing

Inadequacy of the generic falls prevention policy

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.4

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.8

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

Actions described in response 4

Respondent positions 8

Recipient positions 1