PFD report

John Duckenfield · Prevention of Future Deaths report

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Issued 18 Dec 2018•South Yorkshire (Western)

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
5

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Inaccurate and misleading care records
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  2. False reporting of patient observations
  3. Failure to take daily patient observations
    Part of recurring concern: Unreliable patient observation arrangements
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Implement procedures for resident observations, recording, communicating treatment requirements to relatives, and reporting baseline changes to professionals.

    Stated by Brancaster Care Homes LimitedStated completedThe respondent said that this action was complete when they made their response on 13 May 2019.
  2. Action

    Train all registered nurses to complete contemporaneous records in accordance with NMC guidelines.

    Stated by Brancaster Care Homes LimitedStated completedThe respondent said that this action was complete when they made their response on 13 May 2019.
  3. Action

    Conduct scheduled monthly internal and external audits of care records.

    Stated by Brancaster Care Homes LimitedStated completedThe respondent said that this action was complete when they made their response on 13 May 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The omission of daily medical observations did not contribute to the death, which resulted from natural causes.

    Stated by Brancaster Care Homes LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unreliable recording of required observations in care and custody.

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

Implement procedures for resident observations, recording, communicating treatment requirements to relatives, and reporting baseline changes to professionals.

Verbatim wording from the response

“• I attach a procedure regarding observations (resident observation P52) and the recording of such (specific observations F13u and monthly observations F13l). The objective of this procedure is to: ◦ ensure that the residents are observed relevant to their condition/diagnosis; ◦ ensure that the observations are recorded; ◦ make sure relatives are fully aware of the observations and treatment required as a result of the observations; and ◦ ensure changes in baseline observations are reported to other professionals.”

Source location

2018-0389-Response-by-Brancaster-Care-Home
Page 2 · response
Published 13 May 2019

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 all registered nurses to complete contemporaneous records in accordance with NMC guidelines.

Verbatim wording from the response

“• My client organised staff training to ensure that record keeping is undertaken contemporaneously and follows NMC guidelines. All registered nurses attended this training which took place on 3, 8, 9 and 10 January 2019;”

Source location

2018-0389-Response-by-Brancaster-Care-Home
Page 2 · response
Published 13 May 2019

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

Conduct scheduled monthly internal and external audits of care records.

Verbatim wording from the response

“• Audit checks on care records are undertaken by home managers but also by other home managers external to the home on a scheduled monthly basis. These audits are ongoing;”

Source location

2018-0389-Response-by-Brancaster-Care-Home
Page 2 · response
Published 13 May 2019

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

Complete National Early Warning Score training for a registered nurse and provide the new observation policy.

Verbatim wording from the response

“My client notes the concerns in relation to Nurse Bogdan and your referral to his professional body. On 17 January 2019, Nurse ████████ successfully completed an observations training module on National Early Warning Score (NEWS2). I attach his certificate. NEWS2 is a guide used to quickly determine the degree of illness of a patient. It is based on the vital signs, respiratory rate, oxygen saturation, temperature, blood pressure and pulse. Nurse ████████ has also been issued with the new observation policy and signed to acknowledge his understanding and receipt of it.”

Source location

2018-0389-Response-by-Brancaster-Care-Home
Page 2 · response
Published 13 May 2019

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 omission of daily medical observations did not contribute to the death, which resulted from natural causes.

Verbatim wording from the response

“In light of the above, our client’s position is that Mr Duckenfield received reasonable care whilst he was at Pexton Grange despite the fact that daily observations were not carried out. He was receiving constant attention and assessment from the care home. It is also our client’s view that Mr Duckenfield died from natural causes and there was no evidence to suggest that omission to take daily medical observations contributed to the sad death.”

Source location

2018-0389-Response-by-Brancaster-Care-Home
Page 2 · response
Published 13 May 2019

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

Constant attention and assessment by care-home staff were considered reasonable care despite daily medical observations not being undertaken.

Verbatim wording from the response

“assessments of Mr Duckenfield and ████████ (who was employed by the safeguarding team and interviewed ████████) told the court that this was one method of monitoring a patient – the other being the taking of their observations;”

Source location

2018-0389-Response-by-Brancaster-Care-Home
Page 2 · response
Published 13 May 2019

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Rectify issues identified through the 2018 annual audit of Pexton Grange.

    Stated by Brancaster Care Homes LimitedStated completedThe respondent said that this action was complete when they made their response on 13 May 2019.

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

Rectify issues identified through the 2018 annual audit of Pexton Grange.

Verbatim wording from the response

“• My client already undertakes annual audits of homes. The 2018 audit for Pexton Grange of residents, staff and visiting professionals was positive and action has already been taken to rectify any issues arising.”

Source location

2018-0389-Response-by-Brancaster-Care-Home
Page 2 · response
Published 13 May 2019

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026