10 Feb 2020 Christine Rosemary Neild · Prevention of Future Deaths report Manchester South
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Concerns raised 3 Failure to provide reliable overnight detection of residents getting up and wandering View source Failure to escalate incidents involving residents putting non-food items in their mouths and undertake further risk assessment View source Failure to restrict access to gloves for residents who may place items in their mouths View source
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
Action
Deliver additional staff training on risk identification, escalation, safeguarding, basic life support, first aid and incident reporting.
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Action
Carry out resident-specific risk assessments covering glove location, access and associated risks, and communicate outcomes to staff.
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Action
Carry out resident-specific night-time risk assessments covering sleeping patterns and risks from getting out of bed, and communicate outcomes to staff.
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Action
Require all staff to retake the Reporting and Recording e-learning module.
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Action
Provide staff refresher training on key working, capacity, support planning, risk assessment, choking, recording, reporting, first aid and induction.
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Action
Hold a staff meeting addressing the risks of failing to report and record incidents.
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Action
Provide enhanced one-to-one supervision to the Support Worker on reporting and escalating incidents.
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Action
Deliver a reporting and recording training reset for all staff.
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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
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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
Open published response
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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
Open published response
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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
Open published response
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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
Open published response
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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
Open published response
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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
Open published response
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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
Open published response
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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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations