Recipient

Zion Care Limited

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First report 17 Jun 2022•Latest report 17 Jun 2022

Recipient record

Reports, concerns and published responses

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

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. Blackpool and the Fylde

    AI-generated summary

    Margaret Florence Joyce Stringer · 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

    Margaret Florence Joyce Stringer died by suicide between 18.35 and 19.00 on 10 October 2020 in the bathroom adjoining her room at Nightingales Nursing Home. The inquest found that appropriate precautions were not taken, including the return of an item used as a ligature, and that information about her suicide risk was incomplete and insufficiently recognised. Concerns included the absence of a fail-safe system to restrict access to dangerous items and weaknesses in the collation and transfer of information about suicide risk between services.

    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 Zion Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a fail-safe, documented system preventing residents’ access to restricted items

    Wider context from the report

    “1) (Addressed to Nightingales Care Limited and Zion Care Limited, referred to collectively as ‘Nightingales’) Whereas the court heard evidence that Nightingales would not accept another patient with an equivalent medical profile/history and that, should a resident within one of Nightingales’ homes require access to items to be restricted, they would be given 1:1 support pending a mental health assessment and discharge to a more appropriate facility, it was not possible for the home concerned to advise the court as to how and by whom the lead in question had been returned to Mrs Stringer. The concern arises that, in the case of a resident whose care requires access to items to be restricted, there should be a fail-safe, documented system, known to and implemented by staff, by which access to those items by the resident is prevented. In the circumstances that the possibility of a resident requiring such care may still arise, this concern exists notwithstanding the decisions now made. ”
    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 Zion Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain a comprehensive, timely and accessible system for collating and transferring suicide-risk information between service providers

    Wider context from the report

    “3) (Addressed to Lancashire and South Cumbria NHS Foundation Trust, Blackpool Teaching Hospitals NHS Foundation Trust, Lancashire County Council, Nightingales Care Limited and Zion Care Limited (the latter referred to collectively as ‘Nightingales’)) The court heard evidence and/or found that a number of steps had not been taken pertaining to the transfer of information concerning Mrs Stringer’s risk of suicide. They included the following: i. The care coordinator should have requested that the acute hospital make a referral to the Mental Health Liaison Team for a review; ii. It would have been good practice for a further professionals meeting / CPA review to have taken place prior to formal discharge and no later than just after discharge to Nightingales and for the family to have been invited, to ensure that everyone was aware of the plan, that the family was aware of Mrs Stringer’s legal status and to discuss next steps in terms of liaison with other services; iii. There should have been greater professional curiosity and better communication at the time of transfer; iv. The Harbour mental health hospital’s RNNA should have been reviewed to determine whether it needed to be updated and it should have been updated if there was any different clinical information. Further self harm or suicidal ideation, if seen to be significant, should have given rise to a further RNNA; v. There had, in fact, been further indications of self harm and suicidal ideation and, in any event, of a wish to die, on 30th June 2020, in August 2020 and on 3rd September 2020 which were significant and should have been addressed in the information provided to Nightingales and had not been; vi. Mrs Stringer was discharged from The Harbour mental health hospital without an up-to-date Care Act Assessment and, in any event, taking into account the need for Mrs Stringer to be transferred to the acute hospital (which had been necessary), an up-to-date Care Act Assessment had not been completed during the period of her admission to the latter hospital; vii. The risk assessment should have been completed and provided to Nightingales; viii. A positive behaviour support plan should have been completed and provided to Nightingales; ix. A care plan, compliant with CPA Policy and Procedures Key Standard 10, which should have identified a suitable environment in which to manage Mrs Stringer’s risk, her needs and mental health and crisis and contingency planning, to cater for the event of a significant relapse in her mental health, should have been completed and provided to Nightingales; x. Risk behaviour should have been identified to Nightingales and context given, whereas that had not been the case in respect of certain behaviour, including the incident on 30th June 2020; xi. The care coordinator should have been better informed at the points of transfer and discharge; xii. There should have been more robust follow up by the care coordinator whilst Mrs Stringer was at the acute hospital; xiii. There had been no mental health service involvement between the 7-day follow up and 28th September 2020 or, if there had, it had not been recorded; xiv. During the COVID-19 pandemic, it was not possible for a manager to carry out a face-to-face assessment in the mental health hospital but no equivalent measure had been implemented; xv) Whereas it would have been helpful for Nightingales to have received the Continuing Healthcare Checklist, it had not been provided; xvi) Nightingales would have wished to see the risk of suicide referred to in the “Risks to the Service User” section of the FACE Overview Assessment; xvii) The court appointed expert had concerns about the accessibility of key information in the FACE Overview Assessment given the format of that document. Whereas the court heard evidence concerning subsequent, significant, purposeful, developments in practice, the matters listed above can be condensed into a single concern that there should be a comprehensive, cohesive, frictionless system for the timely collation (including from the family and/or other carers) and timely communication / transfer of sufficient, accessible information ((not, simply, risk assessments) pertaining to suicide risk in patients / service users / residents, by and between each of the service providers concerned. ”
    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 Zion Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of staff training on the detrimental effects of isolation and loneliness in elderly people

    Wider context from the report

    “2) (Addressed to Nightingales Care Limited and Zion Care Limited, referred to collectively as ‘Nightingales’) The court heard evidence as to the potential detrimental effects of isolation and loneliness in the elderly, including evidence from the court appointed expert that isolation can be very corrosive, that it is the single most potent causative risk factor for depression in the elderly and that it can have a very detrimental effect on a person’s mental state. There is a need for this to be known amongst staff. The concern arises as one member of staff gave (disputed) evidence that they had little or no training in such matters. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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