Recipient

Northern Care Ltd

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First report 21 Jul 2023•Latest report 21 Jul 2023

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. 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 Northern Care Ltd linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Blackpool and the Fylde

    AI-generated summary

    Steven Duquemin · 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

    Steven Duquemin, a vulnerable man, died after choking on a large piece of raw chicken that he attempted to eat overnight while no carer staff were present. The report identified inconsistent care-record entries and an under-appreciation of his choking risk, with concern that necessary preventative measures might not be implemented promptly for other vulnerable service users.

    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 Northern Care Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in implementing necessary choking-risk preventative measures

    Wider context from the report

    “• Entries in care records were inconsistent, some indicating Steven was not at risk of choking when he clearly was at such risk, and indeed one member of staff gave credible evidence that she had on one occasion have to use skills learned at some recent training to assist Steven after he overfilled his mouth with food. • My concern is quite straight-forward. I received evidence from a Service Manager. In my judgement, in the face of quite overwhelming evidence to the contrary – including a clear medical cause of death reported by the Pathologist - ████████ continued to maintain that Steven had not been at risk of choking, and appeared to stand by entries in care records to the extent they indicated he had not been at risk of choking. • As I indicated at the conclusion of the inquest, it appeared to me that ████████ did not feel anything different ought to have been done, and I formed the view that even if some measures were felt to be necessary to assist service users such as Steven, these were not necessarily going to be implemented with the speed which may be necessary to minimise potential risks. • I found ████████ stance surprising, and I determined that there had been an under – appreciation of the level of risk. It creates an obvious risk to other service users when vulnerable people such as Steven are not appropriately assessed in terms of potential risks. It means necessary preventative measures may not be put in place, and that their lives are at risk as a consequence. • The approach of a relatively senior member of the care staff can, of course, have an impact upon the approach adopted by other personnel and particularly regarding more junior 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 Northern Care Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to appropriately assess and record choking risks for vulnerable service users

    Wider context from the report

    “• Entries in care records were inconsistent, some indicating Steven was not at risk of choking when he clearly was at such risk, and indeed one member of staff gave credible evidence that she had on one occasion have to use skills learned at some recent training to assist Steven after he overfilled his mouth with food. • My concern is quite straight-forward. I received evidence from a Service Manager. In my judgement, in the face of quite overwhelming evidence to the contrary – including a clear medical cause of death reported by the Pathologist - ████████ continued to maintain that Steven had not been at risk of choking, and appeared to stand by entries in care records to the extent they indicated he had not been at risk of choking. • As I indicated at the conclusion of the inquest, it appeared to me that ████████ did not feel anything different ought to have been done, and I formed the view that even if some measures were felt to be necessary to assist service users such as Steven, these were not necessarily going to be implemented with the speed which may be necessary to minimise potential risks. • I found ████████ stance surprising, and I determined that there had been an under – appreciation of the level of risk. It creates an obvious risk to other service users when vulnerable people such as Steven are not appropriately assessed in terms of potential risks. It means necessary preventative measures may not be put in place, and that their lives are at risk as a consequence. • The approach of a relatively senior member of the care staff can, of course, have an impact upon the approach adopted by other personnel and particularly regarding more junior staff. ”
    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