Recipient

Downham Grange

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First report 8 Jun 2022•Latest report 8 Jun 2022

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. 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 Downham Grange linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Norfolk

    AI-generated summary

    Lilian Bernadette BEHRENDT · 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

    Lilian Bernadette Behrendt, aged 91, deteriorated at her care home on 28 November 2021 and died later that evening after being taken to hospital, where she was diagnosed with chest sepsis. The report raised concerns about an incorrectly graded ambulance call, records describing her as “content” despite deterioration, missing observation results, uncertainty about DNACPR and ReSPECT documentation, and unclear responsibility and accountability within the care home.

    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 Downham Grange; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure staff record every care action

    Wider context from the report

    “3) Evidence was originally heard that the Nurse in Charge had been “dismissed” following Mrs Behrendt’s death. At the inquest evidence was heard that “the probationary period had not been extended”. Evidence was heard that the nurse may not have been aware that she was required to record every action and it was accepted that the records in general were “abysmal”, namely those completed by other members of staff. ”
    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 Downham Grange; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to accurately record residents’ deteriorating condition and observation results

    Wider context from the report

    “1) The records relating to Mrs Behrendt referred to her as being “content” throughout the 28 November 2021 and did not refer to her deteriorating condition. There was no record of the result of the observations taken throughout the day or why these were taken, i.e. Mrs Behrendt’s condition was deteriorating and at the request of her family due to their concerns with regard to Mrs Behrendt’s poor presentation. ”
    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 Downham Grange; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of ownership and accountability for overall care home operation

    Wider context from the report

    “6) The evidence revealed a lack of ownership for overall running of the Home, with no one person having or taking responsibility and accountability for the residents, referring to, e.g. Nursing Lead being responsible for DNACPR, nurses “knowing” they should complete the results of observations taken and checking to see that action had been taken Downham Grange Care Home is a relatively small home with a maximum of 62 residents. At the time Mrs Behrendt was a resident the Home had in the region of 48 residents. She had been there since 2018 and the present Manager since May 2021. The Manager had little knowledge of Mrs Behrendt, knowing of her “in passing”. ”
    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 Downham Grange; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of mobile recording devices for recording observation results

    Wider context from the report

    “2) The evidence was that the Nurse taking the observations on 28 November 2021 did not have access to a mobile recording device, which staff are given to use at the Home specifically to record results, although she did have access to a computer on the Unit to input the information. Evidence was heard that the number of mobile recording devices has now increased to 12, which “should be adequate”, but that “they do get lost and broken”. As at the day of the inquest 10 were available to staff to use. ”
    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 Downham Grange; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain clear records of DNACPR and ReSPECT status

    Wider context from the report

    “5) It was unclear from the Home records whether a DNACPR and a ReSPECT form were in place. The Manager had not seen a paper copy and was unclear as to the position. ”
    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