PFD report

Edward Mallaby · Prevention of Future Deaths report

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Issued 10 Dec 2020•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
7

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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

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Concerns raised7

  1. Lack of clarity about required observation frequency for residents at risk of falls
    Part of recurring concern: Inadequate control of falls risksPart of recurring concern: Unreliable patient observation arrangements
  2. Lack of a deadline for completing policy and procedure review with associated training
  3. Failure of fitted sensor mats to activate an alert when a resident is out of bed
    Part of recurring concern: Unreliable fall-mat safety controls
Responses linked to these concerns

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

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.3

  1. Action

    Issue updated resident belongings, resident admission, and falls management policies across the Group, with staff read-and-sign confirmation and Alexandra View supervision sessions.

    Stated by Roseberry Care Centres GB LimitedStated completedThe respondent said that this action was complete when they made their response on 6 January 2021.
  2. Action

    Introduce an Observation and Monitoring form, update the Falls Risk Assessment, and require at least hourly sensor-mat checks throughout each shift with daily senior-management monitoring at Alexandra View.

    Stated by Roseberry Care Centres GB LimitedStated plannedThe respondent said that this action was planned when they made their response on 6 January 2021.
  3. Action

    Repeat Prevention and Management of Falls training for Alexandra View staff.

    Stated by Roseberry Care Centres GB LimitedStated completedThe respondent said that this action was complete when they made their response on 6 January 2021.

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 clarity about required observation frequency for residents at risk of falls

Wider context from the report

“4. Although the deceased had a falls risk assessment, it was not clear whether he was subject to hourly or half hourly observations, or whether the door to his room was to be open or not. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Unreliable patient observation arrangements.

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 a deadline for completing policy and procedure review with associated training

Wider context from the report

“6. A full review of policy and procedure with associated training was apparently underway but without a deadline for completion. ”

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 of fitted sensor mats to activate an alert when a resident is out of bed

Wider context from the report

“2. If a sensor mat was fitted it then it did not activate to alert staff that the deceased was out of bed. ”

Is this part of a recurring concern?

Yes — Unreliable fall-mat safety controls.

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 conduct rapid learning exercises to identify ongoing risks to other residents

Wider context from the report

“5. There appeared to be no rapid learning exercise to ensure that other residents were not at any ongoing risk. ”

Is this part of a recurring concern?

Yes — Failure to identify and address recurring safety issues through organisational learning.

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 of resident alert arrangements to alert staff before routine checks

Wider context from the report

“3. Staff only discovered the deceased “with the TV Box on the top of his legs” on a routine check rather than by a sensor mat or personal alarm call. ”

Is this part of a recurring concern?

Yes — Failure to reliably supervise and monitor residents in care accommodation.

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 a clear policy for handling residents’ potentially hazardous personal property

Wider context from the report

“1. There was no clear policy with the handling of residents’ personal property which may be hazardous. In particular, if the television could not be immediately fitted or stored securely, then the family should be told to arrange another time for it to be delivered and/or remove it. ”

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 clarity about whether a resident’s room door should be open

Wider context from the report

“4. Although the deceased had a falls risk assessment, it was not clear whether he was subject to hourly or half hourly observations, or whether the door to his room was to be open or not. ”

Is this part of a recurring concern?

Yes — Unreliable management of resident bedroom-door status for safe observation.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Issue updated resident belongings, resident admission, and falls management policies across the Group, with staff read-and-sign confirmation and Alexandra View supervision sessions.

Verbatim wording from the response

“Please find enclosed updated policies in respect of:”

Source location

2020-0277-Response-from-Roseberry-Care-Centres-Redacted
Page 1 · response
Published 6 January 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Introduce an Observation and Monitoring form, update the Falls Risk Assessment, and require at least hourly sensor-mat checks throughout each shift with daily senior-management monitoring at Alexandra View.

Verbatim wording from the response

“In addition, I have introduced an Observation and Monitoring form (also enclosed) to be used in accordance with the updated Management and Prevention of Falls policy and updated the Falls Risk Assessment to reference this new record (attached). At the time of Mr Mallaby’s accident, sensor mats were checked at each shift changeover and recorded on the handover by the person in charge. The introduction of this form will ensure sensor equipment is checked for its position and that it is in working order throughout the shift and a minimum of hourly. This amendment to policy and additional checking is being monitored daily at Alexandra View by on site senior management.”

Source location

2020-0277-Response-from-Roseberry-Care-Centres-Redacted
Page 2 · response
Published 6 January 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Repeat Prevention and Management of Falls training for Alexandra View staff.

Verbatim wording from the response

“The staff at Alexandra View have also repeated their Prevention and Management of Falls training to refresh their knowledge; all staff successfully completed this by 7th January 2021.”

Source location

2020-0277-Response-from-Roseberry-Care-Centres-Redacted
Page 2 · response
Published 6 January 2021

Open published response
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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