PFD report

Ruth Gregory · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 11 Jan 2019•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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised1

  1. Lack of supervision of residents in communal areas of care homes
    Part of recurring concern: Failure to control risks posed by care-home residents to themselves and othersPart of recurring concern: Failure to reliably supervise and monitor residents in care accommodation
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.1

  1. Action

    Increase staffing levels across homes, including adding a deputy manager and increasing night cover.

    Stated by Borough Care LtdStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Existing staffing, risk assessments and nurse-call access are considered sufficient to keep communal areas safe despite occasional short unattended periods.

    Stated by Borough Care LtdExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Lack of supervision of residents in communal areas of care homes

Wider context from the report

“The inquest heard that Mrs Gregory's daughter required the knee replacement after being knocked over by another resident in the care home. The inquest was told that residents were regularly left unsupervised in communal areas of the care home and that this meant similar incidents could reoccur leading to trauma and consequential death. There was no detail available at the inquest about how this risk was managed and arrangements to ensure supervision of communal areas. ”

Is this part of a recurring concern?

Yes — Failure to control risks posed by care-home residents to themselves and others; Failure to reliably supervise and monitor residents in care accommodation.

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

Increase staffing levels across homes, including adding a deputy manager and increasing night cover.

Verbatim wording from the response

“This time last year January 2018 we increased the staffing levels in all our homes due to the dependency of the residents we are caring for.”

Source location

2019-0017-Response-by-Borough-Care
Page 1 · response
Published 23 May 2019

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

Existing staffing, risk assessments and nurse-call access are considered sufficient to keep communal areas safe despite occasional short unattended periods.

Verbatim wording from the response

“Whilst there may be occasions when the communal areas are unattended for short periods this has been significantly reduced by the increase in staffing levels.”

Source location

2019-0017-Response-by-Borough-Care
Page 1 · response
Published 23 May 2019

Open published response
Back to top

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