Recipient name withheld

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First report 18 Dec 2018•Latest report 18 Dec 2018

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

Concerns and recipient responses

Statements from Recipient name withheld linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. South Yorkshire (Western)

    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 Recipient name withheld; 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 Recipient name withheld; 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 Recipient name withheld; 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 Recipient name withheld; 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 Recipient name withheld; 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
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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