Concerns raised 5 Inaccurate and misleading care records View source False reporting of patient observations View source Failure to take daily patient observations View source False reporting about requests to call a GP View source Failure to record patient observations View source See 2 more concerns
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. 4
Action
Implement procedures for resident observations, recording, communicating treatment requirements to relatives, and reporting baseline changes to professionals.
View source
Action
Train all registered nurses to complete contemporaneous records in accordance with NMC guidelines.
View source
Action
Conduct scheduled monthly internal and external audits of care records.
View source
Action
Complete National Early Warning Score training for a registered nurse and provide the new observation policy.
View source See 1 more action
×
AI-generated summary
John Duckenfield · 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
John Duckenfield was receiving intermediate care following a fall and was later admitted to Northern General Hospital, where he died on 21 January 2018. The inquest identified concerns about falsely asserted and unrecorded observations, failure to call a GP when requested, and inaccurate or misleading care-home records.
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 Brancaster Care Homes Limited; that does not assign responsibility.
PFD Monitor interpretation Inaccurate and misleading care records
Wider context from the report “During the inquest, evidence showed:-
1. ████████ falsely asserted he had taken observations of Mr Duckenfield in the presence of the family. Not only I, but safeguarding also, felt this assertion was dishonest.
2. He failed to record observations he said he carried out despite accepting a need to do so.
3. Falsely asserted he was never asked to call a GP
4. The care home manager, ████████ said observations should have been taken daily and recorded but were not. Surprisingly therefore, she asserted the care rendered was reasonable.
5. Records kept by the home were inaccurate and misleading .
” 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 Brancaster Care Homes Limited; that does not assign responsibility.
PFD Monitor interpretation False reporting of patient observations
Wider context from the report “During the inquest, evidence showed:-
1. ████████ falsely asserted he had taken observations of Mr Duckenfield in the presence of the family. Not only I, but safeguarding also, felt this assertion was dishonest .
2. He failed to record observations he said he carried out despite accepting a need to do so.
3. Falsely asserted he was never asked to call a GP
4. The care home manager, ████████ said observations should have been taken daily and recorded but were not. Surprisingly therefore, she asserted the care rendered was reasonable.
5. Records kept by the home were inaccurate and misleading.
” 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 Brancaster Care Homes Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to take daily patient observations
Wider context from the report “During the inquest, evidence showed:-
1. ████████ falsely asserted he had taken observations of Mr Duckenfield in the presence of the family. Not only I, but safeguarding also, felt this assertion was dishonest.
2. He failed to record observations he said he carried out despite accepting a need to do so.
3. Falsely asserted he was never asked to call a GP
4. The care home manager, ████████ said observations should have been taken daily and recorded but were not . Surprisingly therefore, she asserted the care rendered was reasonable.
5. Records kept by the home were inaccurate and misleading.
” 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 Brancaster Care Homes Limited; that does not assign responsibility.
PFD Monitor interpretation False reporting about requests to call a GP
Wider context from the report “During the inquest, evidence showed:-
1. ████████ falsely asserted he had taken observations of Mr Duckenfield in the presence of the family. Not only I, but safeguarding also, felt this assertion was dishonest.
2. He failed to record observations he said he carried out despite accepting a need to do so.
3. Falsely asserted he was never asked to call a GP
4. The care home manager, ████████ said observations should have been taken daily and recorded but were not. Surprisingly therefore, she asserted the care rendered was reasonable.
5. Records kept by the home were inaccurate and misleading.
” 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 Brancaster Care Homes Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record patient observations
Wider context from the report “During the inquest, evidence showed:-
1. ████████ falsely asserted he had taken observations of Mr Duckenfield in the presence of the family. Not only I, but safeguarding also, felt this assertion was dishonest.
2. He failed to record observations he said he carried out despite accepting a need to do so .
3. Falsely asserted he was never asked to call a GP
4. The care home manager, ████████ said observations should have been taken daily and recorded but were not. Surprisingly therefore, she asserted the care rendered was reasonable.
5. Records kept by the home were inaccurate and misleading.
” 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 Implement procedures for resident observations, recording, communicating treatment requirements to relatives, and reporting baseline changes to professionals.
Verbatim wording from the response “• I attach a procedure regarding observations (resident observation P52) and the recording of such (specific observations F13u and monthly observations F13l). The objective of this procedure is to:
◦ ensure that the residents are observed relevant to their condition/diagnosis;
◦ ensure that the observations are recorded;
◦ make sure relatives are fully aware of the observations and treatment required as a result of the observations; and
◦ ensure changes in baseline observations are reported to other professionals.” Source location 2018-0389-Response-by-Brancaster-Care-Home
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 Train all registered nurses to complete contemporaneous records in accordance with NMC guidelines.
Verbatim wording from the response “• My client organised staff training to ensure that record keeping is undertaken contemporaneously and follows NMC guidelines. All registered nurses attended this training which took place on 3, 8, 9 and 10 January 2019;” Source location 2018-0389-Response-by-Brancaster-Care-Home
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 Conduct scheduled monthly internal and external audits of care records.
Verbatim wording from the response “• Audit checks on care records are undertaken by home managers but also by other home managers external to the home on a scheduled monthly basis. These audits are ongoing;” Source location 2018-0389-Response-by-Brancaster-Care-Home
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 National Early Warning Score training for a registered nurse and provide the new observation policy.
Verbatim wording from the response “My client notes the concerns in relation to Nurse Bogdan and your referral to his professional body. On 17 January 2019, Nurse ████████ successfully completed an observations training module on National Early Warning Score (NEWS2). I attach his certificate. NEWS2 is a guide used to quickly determine the degree of illness of a patient. It is based on the vital signs, respiratory rate, oxygen saturation, temperature, blood pressure and pulse. Nurse ████████ has also been issued with the new observation policy and signed to acknowledge his understanding and receipt of it.” Source location 2018-0389-Response-by-Brancaster-Care-Home
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 omission of daily medical observations did not contribute to the death, which resulted from natural causes.
Verbatim wording from the response “In light of the above, our client’s position is that Mr Duckenfield received reasonable care whilst he was at Pexton Grange despite the fact that daily observations were not carried out. He was receiving constant attention and assessment from the care home. It is also our client’s view that Mr Duckenfield died from natural causes and there was no evidence to suggest that omission to take daily medical observations contributed to the sad death.” Source location 2018-0389-Response-by-Brancaster-Care-Home
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 Constant attention and assessment by care-home staff were considered reasonable care despite daily medical observations not being undertaken.
Verbatim wording from the response “assessments of Mr Duckenfield and ████████ (who was employed by the safeguarding team and interviewed ████████) told the court that this was one method of monitoring a patient – the other being the taking of their observations;” Source location 2018-0389-Response-by-Brancaster-Care-Home
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations