John Duckenfield

HM Assistant Coroner 
David Urpeth 
The Medico-Legal Centre 
Watery Street 
Sheffield S3 7ES 

By email to: medico-legalcentre@sheffield.gov.uk 

Dear Mr Urpeth 

  CDN/T10295225 

Our Ref: 
Your Ref: 
Date:                  27 February 2019 
Please Ask For:      Chris Newton  
Email: 
Direct Dial: 

  cnewton@keoghs.co.uk 
  023 8190 7002 

Prevention of Future Death Report touching upon the death of Mr John Duckenfield 

I  am  instructed  by  Brancaster  Care  Homes  Limited  to  respond  to  your  regulation  28  report  dated  18 
December 2018.   

This letter responds to the report and includes details of action taken and the date it was taken.   

1.  Your concerns 

My client is concerned at your findings, conclusions and regulation 28 report.  We think it is important to 
note the following points so that your concerns can be put in context: 

  At the time of his admission to Pexton Grange care home on 12 December 2017, Mr Duckenfield 
was suffering from a number of active medical conditions as evidenced by the statement of 

; 

  Pexton Grange cared for Mr Duckenfield with non-medical care staff and nurses. The staff used 
proforma clinical notes to record their involvement with Mr Duckenfield.  You had sight of these 
notes. They record regular interaction with Mr Duckenfield, staff comments, interaction with his 
family and outline the care that Mr Duckenfield received; 

  Nurse 

 said in evidence at the inquest that he carried out more observations of 
Mr Duckenfield than he recorded.  My client accepts however that records must be accurate and 
that  it  was  a  failing  not  to  make  an  accurate  record  but  does  not  accept  that  there  was  any 
intention to mislead; 

  On  29  December  2017  and  the  morning  of  the  2  January  2018,  Doctors 

respectively, examined Mr Duckenfield and saw that his observations were normal. Dr Berry said 
that the oxygen aspirations could fluctuate quite significantly on a daily basis; 

  The  clinical  notes  indicate  that  observations  were  taken  by  Nurse 

  on  30 
December  and  2  January.  The  staff  at  Pexton  Grange  carried  out  regular  interaction  and 

 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 assessments of Mr Dunkenfield and 
and interviewed 
– the other being the taking of their observations; 

 (who was employed by the safeguarding team 
) told the court that this was one method of monitoring a patient 

  Non-medical staff completed fluid charts; 
 

It is agreed that his cause of death was 1a Progressive neurological disorder or unknown aetiology 
and pneumonia; 2 Alcohol related liver disease. 

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 the omission to take daily medical observations 
contributed to the sad death. 

2.  Response – action taken 

My client is constantly reviewing its systems and striving to make them as robust as possible.  Lessons 
have been learned from this investigation and acted upon.  In summary: 

 

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: 

o  ensure that the residents are observed relevant to their condition/diagnosis; 
o  ensure that the observations are recorded; 
o  make sure relatives are fully aware of the observations and treatment required as a 

result of the observations; and 

o  ensure changes in baseline observations are reported to other professionals. 

  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; 

  All registered nurses were issued with the new procedure during their training in January 2019 

and signed to acknowledge their understanding and receipt of it; 

  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; 

  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. 

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. 

2 

 
 My client wishes to conclude by re-iterating that it sincerely regrets the death of Mr Duckenfield but trusts 
that  the  steps  taken  since  demonstrate  its  commitment  to  addressing  your  concerns  in  relation  to 
observations and record keeping.  New procedures are in place with internal and external oversight to 
help ensure compliance. 

Please do let me know if you need any further information.   

Yours sincerely 

Keoghs LLP 

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