Recipient

Recipient name withheld

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First report 18 Dec 2018•Latest report 18 Dec 2018

Recipient record

Reports, concerns and published responses

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 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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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