Misplacement of profile beds reducing sensor effectiveness
Sunrise Senior Living received 2 coroners' reports about this hazard between 15 Dec 2014 and 13 Feb 2017.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“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?”
Original on judiciary.uk ↗ Sunrise Senior Living responded, stating 1 specific action.Response (PDF) ↗
“we now have incorporated this into our manual handling training which is mandatory for all care and nursing staff. Compliance is monitored via manual handling training compliance reports, which are reported weekly to the business. Any concerns on compliance are acted upon by the Director of Operations.”
- 2 years 2 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“The evidence was that fall sensor mats had been placed either side of Mr. [name redacted]' bed on top of crash mats. At the time of his fall on the 3% May 2016 the sensor mats did not sound an alert”
Original on judiciary.uk ↗ Repeated from the earlier report:sensormatscrash
Sunrise Senior Living responded, stating 1 specific action.Response (PDF) ↗Response (PDF) ↗
“I have reviewed practice within the team in relation to the issue of advice and training of this nature and find that it is both consistent and accurate. Furthermore, to support the dissemination of this across the care home sector, a guidance document has been developed outlining good practice in the use of sensor mats and is enclosed for your reference. This was sent on 4 April 2017 to [name redacted] - Acting Strategic Commissioner for Older People, Solihull Metropolitan Borough Council (SMBC)”
Stated timescale: 4 April 2017
- All reports to Sunrise Senior Living
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2014 → 2017Roger Tombs2 years 2 months after Rhys Williams · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports concern the unsafe use of crash mats with sensor mats, questioning whether the mats are positioned correctly to ensure resident safety. The earlier report focuses on staff awareness of rules for mattress and mat placement, while the later report describes actual placement that may reduce sensor effectiveness.
Rhys Williams · 15 Dec 2014
“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?”
Original on judiciary.uk ↗ Roger Tombs · 13 Feb 2017
“The evidence was that fall sensor mats had been placed either side of Mr. [name redacted]' bed on top of crash mats. At the time of his fall on the 3% May 2016 the sensor mats did not sound an alert”
Original on judiciary.uk ↗
Stated action
“we now have incorporated this into our manual handling training which is mandatory for all care and nursing staff. Compliance is monitored via manual handling training compliance reports, which are reported weekly to the business. Any concerns on compliance are acted upon by the Director of Operations.”
No specific action could be extracted with a verified quote.
Stated action · timescale: 4 April 2017
“I have reviewed practice within the team in relation to the issue of advice and training of this nature and find that it is both consistent and accurate. Furthermore, to support the dissemination of this across the care home sector, a guidance document has been developed outlining good practice in the use of sensor mats and is enclosed for your reference. This was sent on 4 April 2017 to [name redacted] - Acting Strategic Commissioner for Older People, Solihull Metropolitan Borough Council (SMBC)”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Sunrise Senior Living at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2014 → 2017 | 0.65 | 0.01 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.