PFD report

Mrs Sheila Sullivan Ross (Sheila) · Prevention of Future Deaths report

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Issued 19 Mar 2018•Sunderland

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.

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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. Poor communication with residents' family members
  2. Use of an outdated falls risk assessment tool
    Part of recurring concern: Unreliable falls risk assessment tools
  3. Failure to record falls risk consistently with the assessment score
    Part of recurring concern: Inadequate control of falls risksPart of recurring concern: Unreliable documentation of safety risk assessments
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

Poor communication with residents' family members

Wider context from the report

“(3) There was poor communication from the Care Home with Sheila’s family members, which led them to lose confidence in the standard of care Sheila was receiving. ”

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

Use of an outdated falls risk assessment tool

Wider context from the report

“(1) The falls risk assessment tool used by the Care Home staff appeared to be outdated, and the subsequent level of falls risk recorded by staff was not in keeping with the score generated by the assessment tool. ”

Is this part of a recurring concern?

Yes — Unreliable falls risk assessment tools.

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 record falls risk consistently with the assessment score

Wider context from the report

“(1) The falls risk assessment tool used by the Care Home staff appeared to be outdated, and the subsequent level of falls risk recorded by staff was not in keeping with the score generated by the assessment tool. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Unreliable documentation of safety risk assessments.

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

Buzzer system failing to support simultaneous activation of personal buzzers and sensor mats

Wider context from the report

“(2) The Care Home buzzer system only allowed one alert mechanism – personal buzzer or sensor mat – to be active at any one time, unless a resident could access the wall buzzer. This can leave residents unable to summon timely assistance when needed. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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