PFD report

Mavis DEWEY · Prevention of Future Deaths report

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Issued 7 Aug 2024•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.

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Concerns: 1
Recipients: 1
Responses found: 1
Stated actions: 13

Recipients and published responses

Monarch Healthcare

No response found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 8 April 2024 I commenced an investigation into the death of Mavis DEWEY. The investigation concluded at the end of the inquest on 07.08.24. The conclusion of the inquest was a narrative, namely:

Mavis Dewey died on 29.03.24 at the Northern General Hospital Sheffield following a fall at the Heeley Bank Care Home Sheffield on the 23.03.24 when staff used incorrect equipment to help her stand in breach of her care plan.
Her death was contributed to by neglect from Heeley Bank Care home.

The Medical Cause of Death was:

1a Multiorgan failure

1b Covid 19 infection and open fracture of right proximal tibia and fibula

II Alzheimer's Disease, Heart Failure

Circumstances of the death

On 07.08.24 I heard the inquest touching the death of Mavis Dewey. Mavis was 89 years old and becoming frailer with a number of underlying health conditions. Her level of need was such that she required residential care which was provided by Heeley Bank Care Home in Sheffield. Mavis' needs were set out in her care plan and there was no dispute that, to be moved or mobilised, she required two members of staff to help her stand together with a standing aid and sling.

On 23.03.24 Mavis was being assisted to stand by two members of staff in her own room. A stand aid was present in her room but so also was a Zimmer frame. It was not possible to establish how the Zimmer frame got there.

Ms Davison for Monarch and Heeley Bank accepted that it was entirely inappropriate for the two members of staff to use the Zimmer frame to help Mavis stand, but this is what they did. As she was being helped to stand, Mavis asked to use the toilet. One member of staff left her with her colleague and supported with the Zimmer frame. Mavis legs gave way and she fell to the floor sustaining a severe gash to her right leg.

An ambulance was called, and she was taken to the Northern General Hospital Sheffield where a fracture to the right proximal tibia and fibula was identified together with a diagnosis of Covid 19.

Despite appropriate care in hospital, Mavis did not recover and she died there on 29.03.23
It remained unclear after evidence why the carers failed to comply with the care plan. I was taken to the care plan which was clear about how moving and handling should take place. The evidence from ████████ was that no full reason was established as to why this happened. Rather, the fact was that the carers simply used the Zimmer frame which was to hand. She said that the carers had sufficient time to work with Mavis. I found that there was no good reason for what they did. This failure led directly to Mavis eventual death.

In evidence it was stated by ████████ that agency staff continued to fail to read care plans on occasion. This concerned me. The care plan sets out the essential requirements to ensure that a resident is safely cared for. I consider that if agency staff are not reading care plans then they may place residents at risk of harm or death just as Mavis was

Concerns and recipient responses

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

Concerns raised1

Failure of agency staff to read care plans

Responses linked to these concerns

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

Actions described in response 4

Action
Read out and reiterate residents’ diagnoses, care needs, moving-and-handling requirements, equipment instructions, staffing requirements and risks.
Stated by Heeley Bank Care HomeStated completed
Action
Induct agency workers and pair them with experienced staff for guidance during shifts.
Stated by Heeley Bank Care HomeStated completed
Action
Provide staff with summary and full care-plan information through mobile devices, tablets, laptops and handover forms.
Stated by Heeley Bank Care HomeStated completed

Respondent positions 1

Position
Appropriate instruction and assessment were in place; the accident resulted from carers’ failure to follow the care plan and moving-and-handling procedures.
Stated by Heeley Bank Care HomeDisputes the concern

Other statements in published responses

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

Recipient-stated actions 9

1
Require all staff to sign attendance at handover meetings on the handover form.
Stated by Heeley Bank Care HomeStated in progress
2
Implement the Daily Clinical Oversight Form and increase management spot checks with reporting to Sheffield Council and the ICB.
Stated by Heeley Bank Care HomeStated completed
3
Screen agency workers through preferred-agency selection, profile checks, registration, references, DBS and training verification.
Stated by Heeley Bank Care HomeStated completed
4
Provide regular agency workers with access to training and competency assessments.
Stated by Heeley Bank Care HomeStated completed
5
Implement routine bedroom audits to check required equipment and remove surplus equipment.
Stated by Heeley Bank Care HomeStated in progress
6
Appoint two Clinical Leads to guide care and nursing teams and complete clinical governance and daily oversight activities.
Stated by Heeley Bank Care HomeStated completed
7
Monitor care delivery through manager walkarounds, spot checks, regional visits, clinical oversight and post-fall CCTV review.
Stated by Heeley Bank Care HomeStated completed
8
Review and implement a Clinical Oversight Form that records moving-and-handling observations in greater detail.
Stated by Heeley Bank Care HomeStated in progress
9
Conduct regular covert CCTV observations of moving-and-handling practice and use footage to support training needs analysis.
Stated by Heeley Bank Care HomeStated in progress

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 raised1

Failure of agency staff to read care plans

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.1

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.9

Actions described in response 4

Respondent positions 1

Recipient-stated actions 9