7 Jan 2025 Sheila Ann Nicholls · Prevention of Future Deaths report Buckinghamshire
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Concerns raised 8 Failure to provide and embed effective life-support training for emergency response View source Failure to conduct adequate investigations of adverse incidents View source Failure to verify and record required review of internal policies View source Failure to maintain emergency-response training through drills and expiry awareness View source Failure to verify staff circulation and understanding of internal policies View source Failure to ensure internal policies are relevant to the nursing home View source Failure to complete training and competency assessment on new policies View source Failure to verify and control ratification and versions of internal policies View source See 5 more concerns
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Sheila Ann Nicholls · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sheila Ann Nicholls died after choking on food during respite care at Mandeville Grange Nursing Home on 19 November 2023. Her family had warned the nursing home about her swallowing difficulties, but important information was not recorded or shared, and she was given food that was unsuitable or insufficiently prepared. The report raised concerns about policy management, emergency response training, and the investigation and learning from adverse incidents.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mandeville Grange Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to provide and embed effective life-support training for emergency response
Wider context from the report “2. At the time of Sheila’s death, of the several staff members that responded to her choking emergency, only one staff member (nurse GC) had currently valid training in life support , but still undertook CPR ineffectively without being corrected by other staff .
Evidence was also given that no simulated emergency drills were ever performed, and some staff were never aware their training had expired.
Whilst nurse GC still works for Grange Mandeville Nursing Home, it is unclear how that nurse will be supported in their ability to provide an adequate emergency response, bearing in mind their existing training appears to have been insufficient.
The deficiency in training and embedding that training, both generally for all staff, and for that specific nurse , creates a risk of death to residents should future emergencies arise.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mandeville Grange Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct adequate investigations of adverse incidents
Wider context from the report “3. Evidence was given of two internal investigations undertaken by Mandeville Grange management following Sheila’s death, both of which failed to adequately consider significant matters . The investigations were performed by staff untrained in investigating adverse incidents . The inability to adequately investigate such matters creates a risk of death to future residents given deficiencies in care may not be identified or remedied in a timely manner.
At the time of the inquest, the nursing home’s expressed intention was to instruct an external person or organisation to investigate future unexpected or unnatural deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mandeville Grange Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to verify and record required review of internal policies
Wider context from the report “1. Mandeville Grange Nursing Home considered several existing policies required improvement, and so they were rewritten following Sheila’s death, some using template documents from a health and safety outsourcing website. However, some rewritten policies still included clauses that remained irrelevant to the nursing home (e.g. regarding ‘oral suction devices’), and several policies remained undated and unsigned, and it was therefore far from clear which policies had been ratified and were in force; with poor version control overall.
It was not always clear when policies had been written or by whom; when and by whom they had been reviewed ; and if and when they were circulated, and to which staff members.
It was also unclear from the evidence of staff members, whether policies were properly embedded and/or understood, and/or had been read by all staff, as there were no checklists confirming staff had read and understood the policies.
At the time of the inquest, staff training on new policies was said to be ongoing, and planned staff competency assessments had yet to be arranged.
Deficient management of internal policies creates a risk of death to future residents where there is an inability to verify and record that all policies:
(a) are relevant to Mandeville Grange in the first instance;
(b) have been ratified and are in force;
(c) have been reviewed as required; and
(d) have been circulated to all relevant staff, with confirmation of those policies having been read and understood.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mandeville Grange Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain emergency-response training through drills and expiry awareness
Wider context from the report “2. At the time of Sheila’s death, of the several staff members that responded to her choking emergency, only one staff member (nurse GC) had currently valid training in life support, but still undertook CPR ineffectively without being corrected by other staff.
Evidence was also given that no simulated emergency drills were ever performed , and some staff were never aware their training had expired .
Whilst nurse GC still works for Grange Mandeville Nursing Home, it is unclear how that nurse will be supported in their ability to provide an adequate emergency response, bearing in mind their existing training appears to have been insufficient.
The deficiency in training and embedding that training, both generally for all staff, and for that specific nurse, creates a risk of death to residents should future emergencies arise.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mandeville Grange Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to verify staff circulation and understanding of internal policies
Wider context from the report “1. Mandeville Grange Nursing Home considered several existing policies required improvement, and so they were rewritten following Sheila’s death, some using template documents from a health and safety outsourcing website. However, some rewritten policies still included clauses that remained irrelevant to the nursing home (e.g. regarding ‘oral suction devices’), and several policies remained undated and unsigned, and it was therefore far from clear which policies had been ratified and were in force; with poor version control overall.
It was not always clear when policies had been written or by whom; when and by whom they had been reviewed; and if and when they were circulated, and to which staff members .
It was also unclear from the evidence of staff members, whether policies were properly embedded and/or understood, and/or had been read by all staff, as there were no checklists confirming staff had read and understood the policies .
At the time of the inquest, staff training on new policies was said to be ongoing, and planned staff competency assessments had yet to be arranged.
Deficient management of internal policies creates a risk of death to future residents where there is an inability to verify and record that all policies:
(a) are relevant to Mandeville Grange in the first instance;
(b) have been ratified and are in force;
(c) have been reviewed as required; and
(d) have been circulated to all relevant staff, with confirmation of those policies having been read and understood.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mandeville Grange Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure internal policies are relevant to the nursing home
Wider context from the report “1. Mandeville Grange Nursing Home considered several existing policies required improvement, and so they were rewritten following Sheila’s death, some using template documents from a health and safety outsourcing website. However, some rewritten policies still included clauses that remained irrelevant to the nursing home (e.g. regarding ‘oral suction devices’), and several policies remained undated and unsigned, and it was therefore far from clear which policies had been ratified and were in force; with poor version control overall.
It was not always clear when policies had been written or by whom; when and by whom they had been reviewed; and if and when they were circulated, and to which staff members.
It was also unclear from the evidence of staff members, whether policies were properly embedded and/or understood, and/or had been read by all staff, as there were no checklists confirming staff had read and understood the policies.
At the time of the inquest, staff training on new policies was said to be ongoing, and planned staff competency assessments had yet to be arranged.
Deficient management of internal policies creates a risk of death to future residents where there is an inability to verify and record that all policies:
(a) are relevant to Mandeville Grange in the first instance;
(b) have been ratified and are in force;
(c) have been reviewed as required; and
(d) have been circulated to all relevant staff, with confirmation of those policies having been read and understood.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mandeville Grange Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to complete training and competency assessment on new policies
Wider context from the report “1. Mandeville Grange Nursing Home considered several existing policies required improvement, and so they were rewritten following Sheila’s death, some using template documents from a health and safety outsourcing website. However, some rewritten policies still included clauses that remained irrelevant to the nursing home (e.g. regarding ‘oral suction devices’), and several policies remained undated and unsigned, and it was therefore far from clear which policies had been ratified and were in force; with poor version control overall.
It was not always clear when policies had been written or by whom; when and by whom they had been reviewed; and if and when they were circulated, and to which staff members.
It was also unclear from the evidence of staff members, whether policies were properly embedded and/or understood, and/or had been read by all staff, as there were no checklists confirming staff had read and understood the policies.
At the time of the inquest, staff training on new policies was said to be ongoing, and planned staff competency assessments had yet to be arranged .
Deficient management of internal policies creates a risk of death to future residents where there is an inability to verify and record that all policies:
(a) are relevant to Mandeville Grange in the first instance;
(b) have been ratified and are in force;
(c) have been reviewed as required; and
(d) have been circulated to all relevant staff, with confirmation of those policies having been read and understood.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mandeville Grange Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to verify and control ratification and versions of internal policies
Wider context from the report “1. Mandeville Grange Nursing Home considered several existing policies required improvement, and so they were rewritten following Sheila’s death, some using template documents from a health and safety outsourcing website. However, some rewritten policies still included clauses that remained irrelevant to the nursing home (e.g. regarding ‘oral suction devices’), and several policies remained undated and unsigned, and it was therefore far from clear which policies had been ratified and were in force; with poor version control overall .
It was not always clear when policies had been written or by whom; when and by whom they had been reviewed; and if and when they were circulated, and to which staff members.
It was also unclear from the evidence of staff members, whether policies were properly embedded and/or understood, and/or had been read by all staff, as there were no checklists confirming staff had read and understood the policies.
At the time of the inquest, staff training on new policies was said to be ongoing, and planned staff competency assessments had yet to be arranged.
Deficient management of internal policies creates a risk of death to future residents where there is an inability to verify and record that all policies:
(a) are relevant to Mandeville Grange in the first instance;
(b) have been ratified and are in force;
(c) have been reviewed as required; and
(d) have been circulated to all relevant staff, with confirmation of those policies having been read and understood.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations