PFD report

Christine Rosemary Neild · Prevention of Future Deaths report

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Issued 10 Feb 2020•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
4

Named on the report

Responses found
2

Of 4 recipients

Stated actions
22

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to provide reliable overnight detection of residents getting up and wandering
    Part of recurring concern: Failure to reliably supervise and monitor residents in care accommodation
  2. Failure to escalate incidents involving residents putting non-food items in their mouths and undertake further risk assessment
    Part of recurring concern: Inadequate management of foreign-body ingestion risks
  3. Failure to restrict access to gloves for residents who may place items in their mouths
    Part of recurring concern: Inadequate management of foreign-body ingestion risks
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.13

  1. Action

    Consult care providers on practical arrangements for safely storing gloves while preserving rapid access for clinical needs.

    Stated by Trafford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 26 November 2020.
  2. Action

    Reiterate that identified or reported risks must be incorporated into care plans and escalated to registered managers for appropriate risk assessment.

    Stated by Trafford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 26 November 2020.
  3. Action

    Continue using enforcement powers to require improvements when providers are not meeting regulatory requirements.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 26 November 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The resident did not require a night sensor because assessments identified no harm risk, while an alert mat could create a trip hazard.

    Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to reliably supervise and monitor residents in care accommodation.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Inadequate management of foreign-body ingestion risks.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Inadequate management of foreign-body ingestion risks.

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

Consult care providers on practical arrangements for safely storing gloves while preserving rapid access for clinical needs.

Verbatim wording from the response

“As you are of course aware, the use of PPE is fundamental to ensure the health and safety of all of our residents during the pandemic and needs to be accessible at all times. We have consulted with our providers to see how we can pragmatically manage the safe storage of gloves in particular.”

Source location

2020-0192-Responses-from-Trafford-Council-and-CQC_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

Reiterate that identified or reported risks must be incorporated into care plans and escalated to registered managers for appropriate risk assessment.

Verbatim wording from the response

“We have re-iterated to our providers, the importance that where any identified/reported need (from any source) is to be incorporated into the person’s care delivery plan and escalated to the Registered Manager of the service. This will ensure that a risk assessment can be completed (where appropriate to do so) and those providing the care are aware of the person’s support needs and can record any observations through established recording and incident reporting mechanisms.”

Source location

2020-0192-Responses-from-Trafford-Council-and-CQC_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

Continue using enforcement powers to require improvements when providers are not meeting regulatory requirements.

Verbatim wording from the response

“Where CQC identifies that regulations are not being met, we use our enforcement powers to require improvements to be made. We continue to do this and will share key learning and practice points from the inquest into the death of Miss Christine Neild with inspectors and registered persons.”

Source location

2020-0192-Responses-from-Trafford-Council-and-CQC_Redacted.pdf
Page 6 · 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

Remind care providers to assess night-time risks and explore technological solutions for supported people who leave their rooms.

Verbatim wording from the response

“Despite the above, we would expect that any individual identified night time risk(s) are suitably risks assessed by the care provider with due consideration of assistive technology as a less restrictive option to mitigating the perceived risk.”

Source location

2020-0192-Responses-from-Trafford-Council-and-CQC_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

Check the provider’s regulatory compliance at the next service inspection and require improvements or highlight breaches where warranted.

Verbatim wording from the response

“We will check the provider’s compliance with the regulations on our next inspection of the service using our key lines of enquiry and in accordance with CQC’s”

Source location

2020-0192-Responses-from-Trafford-Council-and-CQC_Redacted.pdf
Page 5 · 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 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

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The resident did not require a night sensor because assessments identified no harm risk, while an alert mat could create a trip hazard.

Verbatim wording from the response

“From our observations of care planning documents and following discussions with the registered manager of the service Miss Neild did not require a sensor mat to be in place during the night. Support plans and corresponding risk assessments identified Miss Neild was fully mobile during the day and on occasions at night and was not at risk of harm. The inquest heard how Christine would sometimes seek staff out at night as she liked to do this. Placing an alert mat on the floor when someone is fully mobile can present as a trip hazard and becomes an additional risk. Whatever method a service chooses to help keep people safe it must be the least restrictive option, so people retain an element of control and independence in their lives.”

Source location

2020-0192-Responses-from-Trafford-Council-and-CQC_Redacted.pdf
Page 6 · response
Published 26 November 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Routine sensor use cannot be provided because it may restrict liberty without an individual assessment of need and capacity.

Verbatim wording from the response

“When meeting persons assessed needs, we must always ensure that we adhere to the appropriate legal frameworks. The prescriptive use of sensors could not be routinely provided as there may be implications pertaining to a person’s right to liberty (Art 5 ECHR) without a bespoke assessment of need and capacity.”

Source location

2020-0192-Responses-from-Trafford-Council-and-CQC_Redacted.pdf
Page 3 · response
Published 26 November 2020

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.9

  1. 1

    Conduct biannual provider audits using a specific audit tool and incorporate PPE guidance compliance into annual quality reviews.

    Stated by Trafford Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 26 November 2020.
  2. 2

    Share key learning and practice points from the inquest with inspectors and registered persons.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 26 November 2020.
  3. 3

    Share lessons learned from the case through the Provider Forum to disseminate learning across the borough.

    Stated by Trafford Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 26 November 2020.
  4. 4

    Provide and reiterate guidance to care providers on the safe use and disposal of PPE.

    Stated by Trafford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 26 November 2020.
  5. 5

    Complete a lessons-learned log and share it with Trafford Metropolitan Borough Council.

    Stated by Meade CloseStated completedThe respondent said that this action was complete when they made their response on 26 November 2020.
  6. 6

    Prepare a checklist for Support Workers to identify relevant risks during family briefings.

    Stated by Meade CloseStated in progressThe respondent said that this action was in progress when they made their response on 26 November 2020.
  7. 7

    Require Support Workers to obtain, record and escalate family visit briefings about resident risks.

    Stated by Meade CloseStated completedThe respondent said that this action was complete when they made their response on 26 November 2020.
  8. 8

    Provide all staff with a full Salutem induction.

    Stated by Meade CloseStated plannedThe respondent said that this action was planned when they made their response on 26 November 2020.
  9. 9

    Review all staff inductions to verify consistent training coverage.

    Stated by Meade CloseStated in progressThe respondent said that this action was in progress when they made their response on 26 November 2020.

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 biannual provider audits using a specific audit tool and incorporate PPE guidance compliance into annual quality reviews.

Verbatim wording from the response

“As part of our ongoing scrutiny over this matter we plan to conduct bi-annual audits with providers to ensure that the new guidance is being adhered to. We plan to monitor this using a specific audit tool and also to embed it into our annual quality review using a tool called an iTool which is specific to Trafford. Once we have evidence that the practice is embedded it will move to the standard review which is recorded within the iTool.”

Source location

2020-0192-Responses-from-Trafford-Council-and-CQC_Redacted.pdf
Page 1 · 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

Share key learning and practice points from the inquest with inspectors and registered persons.

Verbatim wording from the response

“Where CQC identifies that regulations are not being met, we use our enforcement powers to require improvements to be made. We continue to do this and will share key learning and practice points from the inquest into the death of Miss Christine Neild with inspectors and registered persons.”

Source location

2020-0192-Responses-from-Trafford-Council-and-CQC_Redacted.pdf
Page 6 · 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

Share lessons learned from the case through the Provider Forum to disseminate learning across the borough.

Verbatim wording from the response

“The Provider in this instance has completed a lessons learned which has been shared with their staff. This will be shared with our Provider Forum to ensure the learning from this tragic case is shared across the Borough.”

Source location

2020-0192-Responses-from-Trafford-Council-and-CQC_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 and reiterate guidance to care providers on the safe use and disposal of PPE.

Verbatim wording from the response

“We would like to assure you that we have provided extensive guidance to our providers of the safe usage and disposal of Personal Protective Equipment (PPE). Following the outcome of Miss Neild’s inquest, we have reiterated this message in our daily updates to our providers.”

Source location

2020-0192-Responses-from-Trafford-Council-and-CQC_Redacted.pdf
Page 1 · 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

Complete a lessons-learned log and share it with Trafford Metropolitan Borough Council.

Verbatim wording from the response

“10. We have completed a lessons learned log a copy of which we have shared with Trafford Metropolitan Borough Council for the comment.”

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

Prepare a checklist for Support Workers to identify relevant risks during family briefings.

Verbatim wording from the response

“5. When residents are spending time with their families Support Workers are now required to ask the family member for a briefing of the time they have spent with the resident and to specifically ask whether anything arose during their visit that they think the Care Home staff need to be aware of. Support Workers must record the briefing in the residents’ daily log and escalate any matters that have been identified as a risk. We are preparing a checklist of issues for Support Workers to go through with family members to make sure all relevant risks can be identified.”

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

Require Support Workers to obtain, record and escalate family visit briefings about resident risks.

Verbatim wording from the response

“5. When residents are spending time with their families Support Workers are now required to ask the family member for a briefing of the time they have spent with the resident and to specifically ask whether anything arose during their visit that they think the Care Home staff need to be aware of. Support Workers must record the briefing in the residents’ daily log and escalate any matters that have been identified as a risk. We are preparing a checklist of issues for Support Workers to go through with family members to make sure all relevant risks can be identified.”

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 all staff with a full Salutem induction.

Verbatim wording from the response

“3. A review is being carried out of all staff inductions to make sure all staff members have received the same level of training. It has been agreed that all staff will undergo a full Salutem induction.”

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

Review all staff inductions to verify consistent training coverage.

Verbatim wording from the response

“3. A review is being carried out of all staff inductions to make sure all staff members have received the same level of training. It has been agreed that all staff will undergo a full Salutem induction.”

Source location

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

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026