6 Dec 2018 Veronica Gregory · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 11 Failure to demonstrate how governance of the Home was being managed View source Failure to regularly check the quality of records View source Failure to fully complete appropriate daily observation records View source Inadequate and insufficient care plans addressing specific risk issues View source Failure to ensure sufficient numbers of adequately trained staff View source Lack of appropriate review and reassessment of care plans View source Failure to refer to and comply with appropriate NICE Guidelines View source Failure to make full and appropriate clinical records of physical examinations and resulting actions View source Failure to follow agreed protocols for seeking specific medical help and assistance View source Failure to demonstrate changes in practice and procedure View source Failure to ensure adequate supervision and governance of relevant staff View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 10
Action
Recruit additional registered nurses and nurse team leaders, including through overseas recruitment supported by Home Office sponsorship.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 May 2019. View source
Action
Formulate risk-specific care plans, review them monthly or when needs change, and audit completion and risk management.
Stated completedThe respondent said that this action was complete when they made their response on 12 May 2019. View source
Action
Implement and display a falls protocol and flow chart guiding staff response and escalation after falls.
Stated completedThe respondent said that this action was complete when they made their response on 12 May 2019. View source
Action
Train and remind staff to document incident monitoring, physical examinations, actions taken, and handovers promptly and clearly.
Stated completedThe respondent said that this action was complete when they made their response on 12 May 2019. View source
Action
Introduce management and governance controls including daily checks, incident reviews, walkarounds, resident-of-the-day reviews, online documentation, and wider audits.
Stated completedThe respondent said that this action was complete when they made their response on 12 May 2019. View source
Action
Implement dependency-based staffing assessment, review dependency monthly or as needed, and adjust rotas to assessed resident needs.
Stated completedThe respondent said that this action was complete when they made their response on 12 May 2019. View source
Action
Provide staff access to NICE guidance, clinical procedures, and the Royal Marsden Manual for falls and clinical-care decisions.
Stated completedThe respondent said that this action was complete when they made their response on 12 May 2019. View source
Action
Give staff guidance and competency assessment on when to seek medical help and how to use relevant NICE guidance.
Stated completedThe respondent said that this action was complete when they made their response on 12 May 2019. View source
Action
Conduct regular staff supervision and competency assessments covering resident needs, policies, procedures, and relevant practice.
Stated completedThe respondent said that this action was complete when they made their response on 12 May 2019. View source
Action
Prepare managers to mentor newly appointed overseas nurses through mentorship courses, induction, and training.
Stated plannedThe respondent said that this action was planned when they made their response on 12 May 2019. View source See 7 more actions
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AI-generated summary
Veronica Gregory · 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
Veronica Gregory, who was 83 and living in a nursing and care home, suffered an unwitnessed incident followed by a delayed recognition of pain and a fractured neck of femur. She underwent surgery, developed pneumonia and died on 23 November 2017. The principal concerns included inadequate falls-risk care planning and review, incomplete observation and clinical records, insufficient staffing and supervision, and failures to seek medical assistance promptly.
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 Zinnia Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to demonstrate how governance of the Home was being managed
Wider context from the report “7. A failure to be able to demonstrate, even at the time of the inquest hearing, specifically what changes in practice and procedure had been made, and how the governance of the Home was being managed and regular checking of the quality of all records now being kept.
” 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 Zinnia Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to regularly check the quality of records
Wider context from the report “7. A failure to be able to demonstrate, even at the time of the inquest hearing, specifically what changes in practice and procedure had been made, and how the governance of the Home was being managed and regular checking of the quality of all records now being kept .
” 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 Zinnia Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to fully complete appropriate daily observation records
Wider context from the report “2. A failure to have appropriate daily observation records fully completed .
” 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 Zinnia Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate and insufficient care plans addressing specific risk issues
Wider context from the report “1. Inadequate and insufficient care plans including specific risk issues together with, a lack of appropriate review and reassessment either following an incident or as a matter or general practise.
” 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 Zinnia Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure sufficient numbers of adequately trained staff
Wider context from the report “4. A failure to ensure sufficient numbers of adequately trained staff at all times .
” 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 Zinnia Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate review and reassessment of care plans
Wider context from the report “1. Inadequate and insufficient care plans including specific risk issues together with, a lack of appropriate review and reassessment either following an incident or as a matter or general practise .
” 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 Zinnia Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to refer to and comply with appropriate NICE Guidelines
Wider context from the report “3. A failure to ensure that full and appropriate clinical records of any physical examination and action taken as a result being made. In addition, failure to refer to appropriate NICE Guidelines and comply with them .
” 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 Zinnia Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to make full and appropriate clinical records of physical examinations and resulting actions
Wider context from the report “3. A failure to ensure that full and appropriate clinical records of any physical examination and action taken as a result being made . In addition, failure to refer to appropriate NICE Guidelines and comply with them.
” 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 Zinnia Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to follow agreed protocols for seeking specific medical help and assistance
Wider context from the report “5. A failure to ensure that agreed protocols for seeking specific medical help and assistance were followed in respect of specific incidents .
” 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 Zinnia Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to demonstrate changes in practice and procedure
Wider context from the report “7. A failure to be able to demonstrate, even at the time of the inquest hearing, specifically what changes in practice and procedure had been made , and how the governance of the Home was being managed and regular checking of the quality of all records now being kept.
” 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 Zinnia Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure adequate supervision and governance of relevant staff
Wider context from the report “6. A failure to ensure adequate supervision and governance of all relevant staff
” 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 Recruit additional registered nurses and nurse team leaders, including through overseas recruitment supported by Home Office sponsorship.
Verbatim wording from the response “The home has embarked on extensive recruitment programme and have now recruited more registered nurses and team leaders who are nurses undergoing the IELTS to support the nurses and care staff.” Source location 2018-0377-Response-by-Zinnia-Healthcare
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 Formulate risk-specific care plans, review them monthly or when needs change, and audit completion and risk management.
Verbatim wording from the response “Care plans are now formulated to incorporate specific risk issues like falls; these are risk assessed and reviewed monthly. If a change had occurred since the last review, or occurs in-between this period, the risk is then assessed again with the new change(s) incorporated into the Resident’s care plan.
Care plans are now audited to ensure reviews are done and the risks identified are managed appropriately.” Source location 2018-0377-Response-by-Zinnia-Healthcare
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 Implement and display a falls protocol and flow chart guiding staff response and escalation after falls.
Verbatim wording from the response “In addition to their professional training, all the nurses have access to a copy of the Clinical Procedures on the computer and a hard copy of The Royal Marsden Manual of Clinical Nursing Procedures both of which contain topics on falls prevention and what to do in the event of a fall and a falls protocol is in place and displayed for staff reference.” Source location 2018-0377-Response-by-Zinnia-Healthcare
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 Train and remind staff to document incident monitoring, physical examinations, actions taken, and handovers promptly and clearly.
Verbatim wording from the response “In addition to staff having been trained, they are reminded during staff meetings and one-to-one supervisions to record any incident/accident that occurs during their shift and to hand such over to the next shift.
Staff member must be specific on the type of monitoring that they have undertaken following an incident or accident, e.g. vital signs and physical examination of the Resident. They are reminded that these must be recorded promptly and clearly.” Source location 2018-0377-Response-by-Zinnia-Healthcare
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 Introduce management and governance controls including daily checks, incident reviews, walkarounds, resident-of-the-day reviews, online documentation, and wider audits.
Verbatim wording from the response “There has been change in management. A new Manager who is also a qualified nurse has been employed since February 2018. Changes to practice and procedures have been made: Manager’s daily walk around, accident and incidents reviews, daily checks, Resident of the day implementation, training of relevant staff is undertaken regularly and as when needed, internal documentation changed to online based, wider range of audits are now carried out.” Source location 2018-0377-Response-by-Zinnia-Healthcare
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 Implement dependency-based staffing assessment, review dependency monthly or as needed, and adjust rotas to assessed resident needs.
Verbatim wording from the response “Between August and November 2017, there was a home manager, deputy manager and nurse manager employed in the home, and registered nurses and care staff on duty 24 hours a day. The Directors have always strived to maintain sufficient numbers of adequately trained staff at all times. The home now has in place a staffing dependency tool to meet the assessed needs of the Residents monitored by the present manager.” Source location 2018-0377-Response-by-Zinnia-Healthcare
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 access to NICE guidance, clinical procedures, and the Royal Marsden Manual for falls and clinical-care decisions.
Verbatim wording from the response “From May 2018 several staff competency assessments have been completed. Also, supervision about record keeping have been completed. The Manager has discussed with registered nurses how to access relevant information on NICE guidelines (including NICE Guidelines on head injury), and these are available for staff to access at any time for reference.” Source location 2018-0377-Response-by-Zinnia-Healthcare
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 Give staff guidance and competency assessment on when to seek medical help and how to use relevant NICE guidance.
Verbatim wording from the response “From May 2018 several staff competency assessments have been completed. Also, supervision about record keeping have been completed. The Manager has discussed with registered nurses how to access relevant information on NICE guidelines (including NICE Guidelines on head injury), and these are available for staff to access at any time for reference.” Source location 2018-0377-Response-by-Zinnia-Healthcare
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 Conduct regular staff supervision and competency assessments covering resident needs, policies, procedures, and relevant practice.
Verbatim wording from the response “Supervision and competency assessments are conducted regularly with all staff in a robust fashion, and this comprises all areas of needs of the Residents. The home’s policies and procedures are discussed during one-to-one meetings, supervisions and staff meetings.” Source location 2018-0377-Response-by-Zinnia-Healthcare
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 Prepare managers to mentor newly appointed overseas nurses through mentorship courses, induction, and training.
Verbatim wording from the response “The Directors sourced and procured a Mentorship update course for the Business Manager and a Mentorship course for the Registered Manager and encouraged both to enrol. Both the managers have enrolled on these courses in preparation for the arrival of the newly appointed foreign nurses.” Source location 2018-0377-Response-by-Zinnia-Healthcare
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations