Recipient

Meade Close

First report 10 Feb 2020•Latest report 10 Feb 2020

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Residential care home. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 3
Stated actions: 13

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

13stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Meade Close linked to the concerns in each report. Select any concern, action or position to view the source wording.

10 Feb2020
Manchester South
Concerns raised3
1. Failure to provide reliable overnight detection of residents getting up and wandering
2. Failure to escalate incidents involving residents putting non-food items in their mouths and undertake further risk assessment
3. Failure to restrict access to gloves for residents who may place items in their mouths
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Deliver additional staff training on risk identification, escalation, safeguarding, basic life support, first aid and incident reporting.
  Stated completed
2. Action
  Carry out resident-specific risk assessments covering glove location, access and associated risks, and communicate outcomes to staff.
  Stated completed
3. Action
  Carry out resident-specific night-time risk assessments covering sleeping patterns and risks from getting out of bed, and communicate outcomes to staff.
  Stated completed
1. Action
  Require all staff to retake the Reporting and Recording e-learning module.
  Stated planned
2. Action
  Provide staff refresher training on key working, capacity, support planning, risk assessment, choking, recording, reporting, first aid and induction.
  Stated planned
3. Action
  Hold a staff meeting addressing the risks of failing to report and record incidents.
  Stated completed
4. Action
  Provide enhanced one-to-one supervision to the Support Worker on reporting and escalating incidents.
  Stated completed
5. Action
  Deliver a reporting and recording training reset for all staff.
  Stated planned
AI-generated summary

Christine Rosemary Neild · 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

Christine Rosemary Neild had significant learning difficulties, dysphagia, and required feeding support. She became very unwell and died at Meade Close on 31 January 2020; the medical cause of death was a sub-acute bowel obstruction associated with an incisional hernia. Concerns included accessible gloves and other non-food items, a failure to escalate an earlier ingestion incident or undertake further risk assessment, and the lack of regular sensors to alert staff when residents got up at night.

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 Meade Close; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide reliable overnight detection of residents getting up and wandering
Wider context from the report
“3. The inquest heard that in care settings such as this one for those with learning disabilities there was no regular use of sensors to alert night staff of a resident getting up and wandering. Staff relied on hearing a resident getting up despite this being difficult if they were delivering personal care onto another resident. ”
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 Meade Close; that does not assign responsibility.
PFD Monitor interpretation
Failure to escalate incidents involving residents putting non-food items in their mouths and undertake further risk assessment
Wider context from the report
“2. There had been an earlier incident when Christine Neild had put non-food items in her mouth. The carer did not escalate this and there was no further risk assessment. ”
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 Meade Close; that does not assign responsibility.
PFD Monitor interpretation
Failure to restrict access to gloves for residents who may place items in their mouths
Wider context from the report
“1. During the course of the inquest evidence was heard that gloves were in open and easily accessible locations throughout the home including in rooms and the kitchen area. The inquest was told that this is standard practice in care settings for people with learning disabilities even where residents do not have insight into what items can safely be placed in their mouths. ”
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
Deliver additional staff training on risk identification, escalation, safeguarding, basic life support, first aid and incident reporting.

Verbatim wording from the response
“However, as a result of the issues raised by the Coroner in this case, and as a reminder of the reporting and recording requirements, all staff members have received additional training with regards to identifying risks and then reporting and escalating the concerns in the appropriate way. All staff members have received training in respect of safeguarding adults and children, basic life support, first aid and reporting and recording of incidents.”

Source location
2020-0192-Response-from-Meade-Close-Care-Home_Redacted.pdf
Page 3 · response
Published 26 November 2020
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
Carry out resident-specific risk assessments covering glove location, access and associated risks, and communicate outcomes to staff.

Verbatim wording from the response
“8. We have carried out risk assessments for each resident, specifically in relation to the location of gloves, their access to them and any associate risk. For each resident we have considered the location of the gloves, both in communal areas and their personal bedroom and any risks that present for the individual resident. We assessed the precautions that are already in place and any further steps that need to be taken. A copy of the risk assessment has been placed in the individual residents Care Plan and the outcomes of the assessments have been communicated to all staff members. We will review the risk assessment every six months as a minimum or if an issue arises that prompts an earlier review this will be carried out immediately.”

Source location
2020-0192-Response-from-Meade-Close-Care-Home_Redacted.pdf
Page 3 · response
Published 26 November 2020
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
Carry out resident-specific night-time risk assessments covering sleeping patterns and risks from getting out of bed, and communicate outcomes to staff.

Verbatim wording from the response
“9. We have carried out night time risk assessments for each resident. For each resident we have considered their sleeping pattern and for mobile residents we have considered the risk associated with them getting out of bed. We have assessed the precautions that are already in place and any further steps that need to be taken. A copy of the risk assessment has been placed in the individual residents Care Plan and the outcomes of the assessments have been communicated to all staff members. We will review the risk assessment every six months as a minimum or if an issue arises that prompts an earlier review this will be carried out immediately.”

Source location
2020-0192-Response-from-Meade-Close-Care-Home_Redacted.pdf
Page 3 · response
Published 26 November 2020
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
Require all staff to retake the Reporting and Recording e-learning module.

Verbatim wording from the response
“4. All staff members have undertaken a Reporting and Recording e-learning module however as a result of the issues raised by this case all staff are required to retake the Reporting and Recording e-learning module to refresh their memories and make sure that their learning is up to date.”

Source location
2020-0192-Response-from-Meade-Close-Care-Home_Redacted.pdf
Page 2 · response
Published 26 November 2020
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
Provide staff refresher training on key working, capacity, support planning, risk assessment, choking, recording, reporting, first aid and induction.

Verbatim wording from the response
“discussions took place in respect of staff training and induction. It was agreed that all staff are to undertake refresher training in respect of Key working, Mental Capacity Act, Support planning/risk assessment, choking, recording and reporting, first aid and inductions. We attach a table detailing the actions agreed during the meeting.”

Source location
2020-0192-Response-from-Meade-Close-Care-Home_Redacted.pdf
Page 3 · response
Published 26 November 2020
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
Hold a staff meeting addressing the risks of failing to report and record incidents.

Verbatim wording from the response
“2. A staff meeting has taken place to discuss the issues raised by this case and specifically the risks of not reporting and recording incidents. It was agreed that all staff would have a recording and reporting training reset.”

Source location
2020-0192-Response-from-Meade-Close-Care-Home_Redacted.pdf
Page 2 · response
Published 26 November 2020
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
Provide enhanced one-to-one supervision to the Support Worker on reporting and escalating incidents.

Verbatim wording from the response
“1. Enhanced one to one supervision has been undertaken with the Support Worker involved in the incident when Christine placed a non-food item in her mouth. It is accepted that the Support Worker did not report or record the incident. During the supervision session, the details of the incident were discussed and the importance of reporting incidents of this nature. The Support Worker said that she was aware of the importance of reporting and the reasons why she should. She accepted that in no reporting the incident meant that the incident was not escalated and a risk assessment was not carried out. She is aware of the consequences of not reporting such matters. She was disappointed in herself that she had not done so.”

Source location
2020-0192-Response-from-Meade-Close-Care-Home_Redacted.pdf
Page 2 · response
Published 26 November 2020
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
Deliver a reporting and recording training reset for all staff.

Verbatim wording from the response
“2. A staff meeting has taken place to discuss the issues raised by this case and specifically the risks of not reporting and recording incidents. It was agreed that all staff would have a recording and reporting training reset.”

Source location
2020-0192-Response-from-Meade-Close-Care-Home_Redacted.pdf
Page 2 · response
Published 26 November 2020
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised3

Failure to provide reliable overnight detection of residents getting up and wandering

Failure to escalate incidents involving residents putting non-food items in their mouths and undertake further risk assessment

Failure to restrict access to gloves for residents who may place items in their mouths

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.8

Actions described in response 8