8 Jun 2022 Lilian Bernadette BEHRENDT · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 5 Failure to ensure staff record every care action View source Failure to accurately record residents’ deteriorating condition and observation results View source Lack of ownership and accountability for overall care home operation View source Unavailability of mobile recording devices for recording observation results View source Failure to maintain clear records of DNACPR and ReSPECT status View source See 2 more concerns
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 this recipient says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Audit care records routinely at home and head-office levels, including monthly Downham Grange sampling, and feed findings back to relevant staff.
Stated completedThe respondent said that this action was complete when they made their response on 16 September 2022. View source
Action
Audit homes to confirm DNACPR and ReSPECT forms are uploaded, contact relevant families, and visually flag form status within PCS.
Stated completedThe respondent said that this action was complete when they made their response on 16 September 2022. View source
Action
Provide standardised PCS training through required staff training and centrally accessible induction videos covering recording, assessment, care planning, and changing needs.
Stated completedThe respondent said that this action was complete when they made their response on 16 September 2022. View source
Action
Train Deputy Managers to rebuild handheld-device software when devices become inoperable.
Stated completedThe respondent said that this action was complete when they made their response on 16 September 2022. View source
Action
Revise PCS software to remove emotionally charged dropdown terms, require manual presentation descriptions, and reduce reliance on visual icons.
Stated completedThe respondent said that this action was complete when they made their response on 16 September 2022. View source
Action
Train staff on the revised DNACPR and ReSPECT procedure, including form completion, associated care plans, and use of electronic hospital packs.
Stated completedThe respondent said that this action was complete when they made their response on 16 September 2022. View source
Action
Provide rolling refresher training reinforcing the requirement to record all care and observations in individual service-user records.
Stated completedThe respondent said that this action was complete when they made their response on 16 September 2022. View source
Action
Revise DNACPR and ReSPECT procedures to scan forms into PCS, retain paper originals securely, and provide electronic hospital packs without releasing originals.
Stated completedThe respondent said that this action was complete when they made their response on 16 September 2022. View source
Action
Increase Downham Grange recording capacity by purchasing three handheld devices and enabling PCS access on medication devices for nurses.
Stated completedThe respondent said that this action was complete when they made their response on 16 September 2022. View source
Action
Establish PCS Champions in every home to provide bespoke support, rolling bite-size training, and feedback on recurring software-use issues.
Stated completedThe respondent said that this action was complete when they made their response on 16 September 2022. View source See 7 more actions
×
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 Kingsley Care Homes Limited; 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 Kingsley Care Homes Limited; 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 Kingsley Care Homes Limited; 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 Kingsley Care Homes Limited; 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 Kingsley Care Homes Limited; 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
×
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 Audit care records routinely at home and head-office levels, including monthly Downham Grange sampling, and feed findings back to relevant staff.
Verbatim wording from the response “In order to prevent a recurrence, and ensure that staff are compliant with the training which has been provided to them, the Company regularly audits care plans – at both local level by the home management, as well as the Company’s Head Office. Both audits involve a thorough and wholesale review of records, to include reference to the inclusion of routine observations. Downham Grange’s senior management dip sample audit the PCS records of three service users every month. Feedback from the audits is provided to staff, either individually or, where more general issues of practice are identified, to all relevant staff.” Source location Response from Kingsley Healthcare
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 Audit homes to confirm DNACPR and ReSPECT forms are uploaded, contact relevant families, and visually flag form status within PCS.
Verbatim wording from the response “To ensure that all forms within its homes have been uploaded, audits have been undertaken at each site to identify all service users in receipt of the same. All families of service users with these forms in place have been contacted, to ensure that they are aware of their existence. In addition, to identify at a glance which service users have a DNACPR/ReSPECT form in place, the PCS has been updated and the relevant section is now highlighted in red for those service users with a DNACPR in place; and blue for those without a DNACPR in place.” Source location Response from Kingsley Healthcare
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 standardised PCS training through required staff training and centrally accessible induction videos covering recording, assessment, care planning, and changing needs.
Verbatim wording from the response “All staff who are required to create entries within the PCS as part of their role have received training in respect of the above revisions, as well being reminded of the need to fully record comprehensive and contemporaneous records. To ensure consistency of training across all sites, the Company has produced two training videos, which are delivered by the Director of Compliance and reflect real-life examples from within the Company as a whole. Each video is approximately two hours long and are shown to new starters as part of their induction. In addition, the videos are electronically stored in a central location and are accessible to staff whenever required to be viewed.” Source location Response from Kingsley Healthcare
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 Deputy Managers to rebuild handheld-device software when devices become inoperable.
Verbatim wording from the response “On occasion the mobile recording devices do become inoperable, as a result of software issues, and the Company does arrange for repair and replacement of them when required. The Company has also now provided training to its Deputy Managers so that they have the skills and knowledge to re-build the software within each handheld device should they become inoperable.” Source location Response from Kingsley Healthcare
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 Revise PCS software to remove emotionally charged dropdown terms, require manual presentation descriptions, and reduce reliance on visual icons.
Verbatim wording from the response “As a result of this concern the Company engaged with its external software engineers and requested that all pre-loaded emotionally-charged words within the PCS, including references to ‘content,’ be removed entirely from the drop-down lists within the programming. The word has not been replaced and instead staff are now required to manually enter into care records a description of each individual service user’s presentation and assessment of their happiness rating. This change has been applied across all of the homes operated by the Company and the revised software has now gone live.” Source location Response from Kingsley Healthcare
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 staff on the revised DNACPR and ReSPECT procedure, including form completion, associated care plans, and use of electronic hospital packs.
Verbatim wording from the response “Following Mrs Behrendt’s death the Company has provided all staff with training on the new procedure and has specifically directed them that original paper documentation is not to be supplied to ambulance crews, and that instead the electronic hospital pack must be printed from the PCS.” Source location Response from Kingsley Healthcare
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 rolling refresher training reinforcing the requirement to record all care and observations in individual service-user records.
Verbatim wording from the response “The Company disputes the suggestion that the NIC – or any member of staff – was unaware of the requirement to record every action. Not only is this an explicit requirement within the NMC’s Code of Conduct (and in respect of which, the Company submits, the NIC would have been intimately familiar as a result of her professional training and qualifications), but was also included within the Company’s training, as detailed above. Following Mrs Behrendt’s death the Company has reinforced its expectation, by way of rolling refresher training, that all care provided and observations taken must be recorded within each individual service user’s care records.” Source location Response from Kingsley Healthcare
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 Revise DNACPR and ReSPECT procedures to scan forms into PCS, retain paper originals securely, and provide electronic hospital packs without releasing originals.
Verbatim wording from the response “To avoid a repeat of this possible situation, the Company has revised its system to ensure that DNACPR and ReSPECT forms are retained at all times. For example, if a service user is admitted to Downham Grange from hospital, the relevant DNACPR/ReSPECT form will accompany them to the Home in paper form. Conversely, if a service user is already resident within the Home and is placed on end of life care, the GP will complete the relevant form. In both instances, the paper form is now scanned and uploaded into the PCS. The paper versions will also be retained in each service user’s dedicated papers file, which is kept in the Home Manager’s office.” Source location Response from Kingsley Healthcare
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 Increase Downham Grange recording capacity by purchasing three handheld devices and enabling PCS access on medication devices for nurses.
Verbatim wording from the response “Downham Grange has purchased three additional devices for use following the recent inquest request. In addition, the Company has also uploaded the PCS App onto its medication handheld devices, so that registered nurses are now able to access both the PCS and medication software on one device. The medication devices are in addition to the handheld devices and laptops for use by the nurses. The Company considers that the number of units available in the Home is sufficient for the number of staff on duty at any given time.” Source location Response from Kingsley Healthcare
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 Establish PCS Champions in every home to provide bespoke support, rolling bite-size training, and feedback on recurring software-use issues.
Verbatim wording from the response “Following the death of Mrs Behrendt, the Company has provided PCS refresher training to all staff who are required to use the software as part of their role. In addition the Company has this year created within all of its homes the new role of PCS Champion, to act as a first point of liaison for all staff should they have any queries in respect of the software. This role is undertaken by individuals in addition to their primary role within the business, and Champions are selected for the position based on their existing demonstrable understanding and proficiency with the software. The PCS Champions had training on 30 March 2022.” Source location Response from Kingsley Healthcare
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 Company disputes that staff were unaware of how to use PCS or the requirement to record every action.
Verbatim wording from the response “The Company strongly disputes any suggestion that the NIC, or any member of staff who is required as part of their role to update the PCS, is unaware of how to use or upload comments into it.” Source location Response from Kingsley Healthcare
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 Company considers it impractical for one Home Manager to undertake all responsibilities or know every service user intimately.
Verbatim wording from the response “The Company accepts that its Registered Managers each have ultimate responsibility for all aspects of their individual homes. That being said and due to the volume of issues and care needs to be addressed on any given day, the Company does not consider that it is practical or possible for any one individual to undertake all these roles and responsibilities, or for them to have an intimate knowledge of every single service user.” Source location Response from Kingsley Healthcare
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 Company considers computer access at nearby nursing stations sufficient for nurses to record PCS entries without assigned mobile devices.
Verbatim wording from the response “The mobile recording devices are allocated to care assistants during each shift for their use and ease of recording entries within service users’ care records. In addition, the Company provides separate computers for each nurse within every home, for their specific use. Nurses are not assigned a mobile recording device as they are expected, and are directed during their initial training, to record their entries within the PCS software via the computers. The computers are located within the nursing stations. Although the NIC was not expected to have personal access to a mobile recording device, access to the PCS was available via the computers. Mrs Behrendt’s room was located a few yards from the nurse’s station and the Company is satisfied that this system is sufficient in the circumstances.” Source location Response from Kingsley Healthcare
Open published response
25 Apr 2016 Marjorie Wood · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of clarity or knowledge about the legal status of individuals in care homes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Marjorie Wood · 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
Marjorie Wood, who had dementia and was residing at Timperley Care Home, was found deceased there on 2 December 2015. The principal concern was that the care home did not know whether she was subject to a Deprivation of Liberty Safeguarding application or whether this affected her care and treatment, although no evidence showed that this lack of clarity affected her in this case.
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 Kingsley Care Homes Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity or knowledge about the legal status of individuals in care homes
Wider context from the report “Whilst there was no evidence in this case that the lack of clarity or knowledge in this particular case made a difference to the deceased, it is important that there is a full understanding of the legal status of an individual who is in a care home as this may impact on their care and treatment needs.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations