Recurance · prevention of future deaths reports
Pre-inquest brief
Misplacement of profile beds reducing sensor effectiveness
The earlier warning
Rhys Williams · 15 Dec 2014 · John Pollard, Manchester (South)
“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?”
judiciary.uk/prevention-of-future-death-reports/rhys-williams
What was promised
Stated action 1 · response to Rhys Williams (15 Dec 2014) · stated timescale: none stated
“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.”
judiciary.uk/…/2014-0558-Response-by-Sunrise-Senior-Living.pdf
What recurred
- 13 Feb 2017 · Roger Tombs · Emma Brown · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · 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?”
Later · 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”
What happened next
No web check of the stated actions has been published for this chain.