Lilian Behrendt

HM Coroner for Norfolk 
County Hall 
Norwich 
NR1 2DH 

29 July 2022 

Dear Madam 

Inquest touching upon the death of Lilian Behrendt – Rule 28 response 

Thank you for your letter dated 9 June 2022. 

Kingsley Care Homes Limited (‘the Company’) owns and operates Downham Grange Care Home and provides 
this reply in response to the concerns highlighted. 

For completeness, following the inquest which was heard on 19 May 2022 Downham Grange has recently been 
inspected  by  the  Care  Quality  Commission.  Although  the  final  inspection  report  is  awaited,  verbal  feedback 
provided  to  the  Home’s  management  team  has  been  positive  with  no  breaches  of  regulations  noted  and  the 
Company is now awaiting the draft report. 

Concern 1 

The records relating to Mrs Behrendt referred to her as being “content” throughout the 28 November 2021 
and  did  not  refer  to  her  deteriorating  condition.  There  was  no  record  of  the  result  of  the  observations 
taken throughout the day or why these were taken, i.e. Mrs Behrendt’s condition was deteriorating and at 
the request of her family due to their concerns with regard to Mrs Behrendt’s poor presentation. 

The  Company  accepts  that  this  was  a  limitation  within  its  Person  Centred  Software  (‘PCS’)  electronic  care 
management and recording system at the time of Mrs Behrendt’s death, which restricted staff to a binary drop-
down choice and did not always allow for nuance. 

As a result of this concern the Company engaged with its external software engineers and requested that all pre-
loaded emotionally-charged words within the PCS, including references to ‘content,’ be removed entirely from the 
drop-down lists within the programming. The word has not been replaced and instead staff are now required to 
manually enter into care records a description of each individual service user’s presentation and assessment of 
their happiness rating. This change has been applied across all of the homes operated by the Company and the 
revised software has now gone live. 

The  Company  considers  that  this  software  update  avoids  entirely  the  possibility  of  a  repeat  occurrence  of  the 
above scenario. 

In  addition,  the  use  of  indicative  visual  icons  within  the  PCS  has  been  significantly  reduced  so  as  to  avoid 
miscommunication and again to encourage staff to write entries rather than reliance on visual indicators. 

All staff who are required to create entries within the PCS as part of their role have received training in respect of 
the  above  revisions,  as  well being  reminded  of  the  need  to  fully record  comprehensive  and  contemporaneous 
records. To ensure consistency of training across all sites, the Company has produced two training videos, which 
are delivered by the Director of Compliance and reflect real-life examples from within the Company as a whole. 
Each video is approximately two hours long and are shown to new starters as part of their induction. In addition, 
the  videos  are  electronically  stored  in  a  central  location  and  are  accessible  to  staff  whenever  required  to  be 
viewed. 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
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29 July 2022 

The videos cover all aspects of the PCS software and its operation, including detailing admissions processes, the 
requirement to undertake initial risk assessments, completion of the service user profile/ ‘front page’ information, 
care planning and updating of records in light of changing needs. These videos were in development prior to the 
death of Mrs Behrendt but have now gone live and are in use within the organisation. Specifically in light of the 
above  concern, the videos advise and remind staff of  the need to manually enter  a description of each service 
user’s presentation when care is provided, to ensure accuracy and that the entries are person-centred. 

In respect of entries generally on 28 November 2021, the Company considers that it has been fundamentally let 
down by the Nurse in Charge (‘NIC’) and is disappointed as to her apparent disregard for her own professional 
obligations  and  adherence  to  the  training  that  had  been  provided  to  her,  both  inherent  within  her  professional 
qualification  as  well  as  that  provided  to  her  by the  Company.  The  Company  distances  itself  from  her  actions, 
submits that her omissions were not condoned by it and should be not vicariously ascribed to it. 

At the time of Mrs Behrendt’s death the NIC had been qualified and registered as a Nurse for around two years. 
She was considered experienced and, prior to working at Downham Grange, had worked in another adult social 
care home. She was deemed to be familiar with both the sector and her own professional obligations, including 
those  contained  within  the  NMC’s  Code  of  Conduct.  There  was  no  aspect  of  her  application  or  previous 
experience which indicated or suggested that she was not suitable for the role at Downham Grange. 

Despite her qualification and previous experience, and as per standard Company policy, the NIC’s employment 
with the Company was subject to an initial probationary period of six months, during which time her suitability for 
the role was to be assessed. On the commencement of her employment the NIC received initial induction training 
from the Company, not only in respect of use of the PCS but also in relation to her specific role, responsibilities 
and duties including the importance of recording care provided. This initial training, which lasted for three days, 
was supplemented by work shadowing for her first three shifts and a subsequent supervision review after around 
four weeks. This session took the form of a sit-down meeting with the NIC to review both feedback provided in 
respect of her practice, as well as to further assess her ongoing suitability for the role. 

For completeness, the Company expects registered nurses to have a level of competency and awareness of their 
own professional obligations. It was stressed to the NIC during her initial period with the Company that not only 
should she comply with her own professional obligations, as contained within the NMC’s Code of Conduct (which 
includes, at paragraph 10, the requirement to keep clear and accurate records), but also the training provided to 
her by the Company. 

Through  the  training  and  induction  provided,  the  Company  is  satisfied  that  all  staff  are  aware  of  the  internal 
escalation  procedure  should  they  require  a  second  opinion  or  advice.  For  example,  within  each  Home  a 
management on-call function is always available and provided by the Manager or Deputy Manager.  In addition, 
the Company’s  senior Operations team are  visible  within the business and  is  also  available to  provide support 
and  assistance  when  required.  The  availability  of  this  support  network  is  highlighted  to  staff,  and  has  been 
reinforced since the recent inquest. 

In addition to the above mandatory training, the Company provides regular refresher training, including in the use 
of  the PCS.  Staff  are also  able  to request  additional  training  should  they consider  this necessary for their  own 
professional development. 

The Company strongly disputes any suggestion that the NIC, or any member of staff who is required as part of 
their role to update the PCS, is unaware of how to use or upload comments into it. 

Following  the  death  of  Mrs  Behrendt,  the  Company  has  provided  PCS  refresher  training  to  all  staff  who  are 
required to use the software as part of their role. In addition the Company has this year created within all of its 
homes the new role of PCS Champion, to act as a first point of liaison for all staff should they have any queries 
in  respect  of  the  software.  This  role  is  undertaken  by  individuals  in  addition  to  their  primary  role  within  the 
business, and Champions are selected for the position based on their existing demonstrable understanding and 
proficiency with the software. The PCS Champions had training on 30 March 2022. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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29 July 2022 

The  role  of  PCS  Champion  is  to  provide  an  additional  level  of  support  –  over  and  above  the  training  and 
information provided by the Company – to ensure that staff are continually supported in their use of the software. 
For example, within each home the PCS Champion will undertake individual bitesize training sessions with staff, 
with  the  content  being  bespoke  to  each  home  and  based  on  examples  identified  as  a  result  of  that  site’s  own 
internal care record audits, to reinforce best practice. For the avoidance of doubt, if there are repeated issues of 
non-compliance by any member of staff, in respect of the PCS or more generally, then this can lead to disciplinary 
proceedings and/ or dismissal in appropriate instances. 

The PCS Champions feed back to the Director of Compliance, to enable identification of recurrent or persistent 
issues across the Company’s homes, and to take further actions if and when required to ensure that the training 
remains relevant. 

The  training  delivered  by  each  home’s  PCS  Champion  is  provided  on  a  rolling  basis  and  when  issues  are 
identified, to ensure that there is on-going learning within each site which is specific to the issues identified at that 
site. The Company considers that this ongoing training negates entirely any future suggestions by staff that they 
are unsure how to use the software. 

As  a  result  of  both  observations  of  the  NIC’s  practice  during  her  probationary  period,  and  following  feedback 
received, the Company did not consider that it was appropriate for her to remain in its employment. Specifically 
as a result of her failure to abide by her own professional obligations and omission to contemporaneously record 
Mrs Behrendt’s observations on 28 November 2021, the Company referred the NIC to the NMC. 

In order to prevent a recurrence, and ensure that staff are compliant with the training which has been provided to 
them,  the  Company regularly audits  care  plans  – at  both  local  level  by the  home  management,  as well  as the 
Company’s Head Office. Both audits involve a thorough and wholesale review of records, to include reference to 
the inclusion of routine observations. Downham Grange’s senior management dip sample audit the PCS records 
of  three  service  users every month.  Feedback  from  the audits  is provided  to  staff,  either  individually or,  where 
more general issues of practice are identified, to all relevant staff. 

Where  individual service users have  specific  care needs,  for  example fluid requirements or a  need  for turning, 
the  PCS  enables  the  home’s  senior  management  to  access  that  individual’s  electronic  records  and  review 
specifically the fluid or turn charts as required. The home’s senior management check all such entries on a daily 
basis, to ensure that appropriate care is being provided and the needs of service users are being met. 

By way of on-going monitoring, Downham Grange also conducts a daily ‘11 at 11’ meeting which is attended by 
all heads of department, and will include consideration of any developing issues, concerns of service user-specific 
issues which may arise and require attention. 

Concern 2 

The evidence was that the Nurse taking the observations on 28 November 2021 did not have access to a 
mobile recording device, which staff are given to use at the Home specifically to record results, although 
she  did  have  access  to  a  computer  on  the  Unit  to  input  the  information.  Evidence  was  heard  that  the 
number of mobile recording devices has now increased to 12, which “should be adequate”, but that “they 
do get lost and broken”. As at the day of the inquest 10 were available to staff to use. 

The mobile recording devices are allocated to care assistants during each shift for their use and ease of recording 
entries within service users’ care records. In addition, the Company provides separate computers for each nurse 
within every home, for their specific use. Nurses are not assigned a mobile recording device as they are expected, 
and are directed during their initial training, to record their entries within the PCS software via the computers. The 
computers are located within the nursing stations. Although the NIC was not expected to have personal access 
to  a  mobile  recording  device,  access  to  the  PCS  was  available  via  the  computers.  Mrs  Behrendt’s  room  was 
located  a  few  yards  from  the  nurse’s  station  and  the  Company  is  satisfied  that  this  system  is  sufficient  in  the 
circumstances. 

Had  the  NIC  required  immediate  access  to  a  mobile  recording  device  then  she  could  have  asked  to  borrow  a 
colleague’s, or could have accessed the computer at the nearby nurse’s station. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
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On occasion the mobile recording devices do become inoperable, as a result of software issues, and the Company 
does arrange for repair and replacement of them when required. The Company has also now provided training to 
its  Deputy Managers  so that  they have  the skills  and  knowledge to  re-build  the  software  within  each handheld 
device should they become inoperable. 

Downham Grange has purchased  three  additional devices for use following the  recent inquest. In  addition, the 
Company has also uploaded the PCS App onto its medication handheld devices, so that registered nurses are 
now able to access both the PCS and medication software on one device. The medication devices are in addition 
to  the  handheld  devices  and  laptops  for  use  by  the  nurses.  The  Company  considers  that  the  number  of  units 
available in the Home is sufficient for the number of staff on duty at any given time. 

Concern 3 

Evidence was originally heard that the Nurse in Charge had been “dismissed” following Mrs Behrendt’s 
death. At the inquest evidence was heard that “the probationary period had not been extended”. Evidence 
was heard  that the nurse may not have been aware that she was  required  to  record  every action and  it 
was accepted that the records in general were “abysmal”, namely those completed by other members of 
staff. 

It  is  correct  that  following  Mrs Behrendt’s  death  the  NIC’s probationary period  was not  extended,  and  she  was 
dismissed from the organisation. 

Whilst the Company accepts that  it was open to it  to  extend the NIC’s  probationary period  as an  alternative to 
dismissal,  in  light  of  the  concerns  arising  from  Mrs  Behrendt’s  death  the  Company  took  the  decision  that  this 
would not be appropriate. Given the extent to which she had failed to discharge her individual responsibilities, the 
Company decided to dismiss her and additionally referred her to the NMC. 

The Company disputes the suggestion that the NIC – or any member of staff – was unaware of the requirement 
to record every action. Not only is this an explicit requirement within the NMC’s Code of Conduct (and in respect 
of which, the Company submits, the NIC would have been intimately familiar as a result of her professional training 
and  qualifications),  but  was  also  included  within  the  Company’s  training,  as  detailed  above.  Following  Mrs 
Behrendt’s death the Company has reinforced  its  expectation,  by way of rolling  refresher  training,  that  all  care 
provided and observations taken must be recorded within each individual service user’s care records. 

This revised training programme is supplemented by the enhanced auditing system, as detailed above. 

Concern 4 

The  Nurse  in  Charge  had  contacted  another  member  of  staff  to  comment  on  Mrs  Behrendt’s  general 
presentation as she [NIC] had not worked with Mrs Behrendt for over a month, having been placed on a 
different Unit. 

The Company accepts that the NIC had worked on a different unit prior to 28 November 2021. 

However, the Company considers that it is both appropriate and necessary for nurses within its homes to have 
experience of working across all units within each home (for example, residential, dementia and nursing) to both 
maintain  their  professional  competency,  and  to  also  ensure  their  familiarity  with  all  aspects  of  each  individual 
home. The Company does not propose to revise this system and considers that it is of benefit to both the service 
users and home staff. 

By contrast, care assistants do not move between units. This allows them to build meaningful relationships with 
their  service  users  and  enables  them  to  develop  a  deep  understanding  and  knowledge  of  their  specific  care 
needs. The Company encourages teamwork and for individuals to seek assistance when required. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
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Concern 5 

29 July 2022 

It  was  unclear  from  the  Home  records  whether  a  DNACPR  and  a  ReSPECT  form  were  in  place.  The 
Manager had not seen a paper copy and was unclear as to the position. 

The Company is satisfied that the appropriate forms were in place in respect of Mrs Behrendt and refers to the 
read evidence of the training hospital clinicians, which confirms that a DNACPR form was available.  Following 
internal review and audit the Company understands that on occasion, the paper DNACPR form may have been 
accidentally provided to ambulance crews on their attendance, rather than a copy being provided. 

To  avoid  a repeat  of  this  possible  situation,  the Company has  revised its system  to  ensure  that  DNACPR  and 
ReSPECT forms are retained at all times. For example, if a service user is admitted to Downham Grange from 
hospital, the relevant DNACPR/ ReSPECT form will accompany them to the Home in paper form. Conversely, if 
a  service  user  is  already resident  within  the  Home  and  is  placed  on  end  of  life  care,  the  GP  will  complete  the 
relevant form. In both instances, the paper form is now scanned and uploaded into the PCS. The paper versions 
will also be retained in each service user’s dedicated papers file, which is kept in the Home Manager’s office. 

Once uploaded into PCS, the DNACPR will be populated into that service use’s hospital pack. If that individual is 
subsequently admitted to hospital the hospital pack will be printed out and handed to the ambulance crew. The 
paper version will be retained by the home at all times for its records. There is no longer any need for the paper 
forms  to  leave  the  home,  or  any  scope  for  individual  forms  to  be  misplaced  as  an  electronic  copy  will  always 
remain available to the home. 

Following Mrs Behrendt’s death the Company has provided all staff with training on the new procedure and has 
specifically directed them that original paper documentation is not to be supplied to ambulance crews, and that 
instead the electronic hospital pack must be printed from the PCS. 

To ensure that all forms within its homes have been uploaded, audits have been undertaken at each site to identify 
all  service  users  in  receipt  of  the  same.  All  families  of  service  users  with  these  forms  in  place  have  been 
contacted, to ensure that they are aware of their existence. In addition, to identify at a glance which service users 
have a DNACPR/ ReSPECT form in place, the PCS has been updated and the relevant section is now highlighted 
in red for those service users with a DNACPR in place; and blue for those without a DNACPR in place. 

Training has also been  provided  to  staff  in respect  of  the  completion  of  these forms, as well as the associated 
care plans, to ensure that that there is no potential for confusion as to an individual’s wishes. 

The  Company is  confident  that  as  a result  of  the  above procedures,  it  has negated entirely the  possibility of  a 
repeat occurrence. 

Concern 6 

The evidence revealed a lack of ownership for overall running of the Home, with no one person having or 
taking  responsibility  and  accountability  for  the  residents,  referring  to,  e.g.  Nursing  Lead  being 
responsible for DNACPR, nurses “knowing” they should complete the results of observations taken and 
checking to see that action had been taken Downham Grange Care Home is a relatively small home with 
a  maximum of 62  residents. At the time Mrs  Behrendt was a resident the Home had  in the  region  of  48 
residents.  She  had  been  there  since  2018  and  the  present  Manager  since  May  2021.  The  Manager  had 
little knowledge of Mrs Behrendt, knowing of her “in passing”. 

The Company does not consider that Downham Grange, as a 62-bed nursing home, can be accurately described 
as small within the sector and considers that it would be more appropriately classed as a medium to large home. 
Even  with  the  48  residents  at  the  time  of  Mrs  Behrendt’s  death,  the  Company  submits  that  this  would  still  be 
considered a medium-sized home. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
  
 
 
 
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The  Company  accepts  that  its  Registered  Managers  each  have  ultimate  responsibility  for  all  aspects  of  their 
individual homes. That being said and due to the volume of issues and care needs to be addressed on any given 
day, the Company does not consider that it is practical or possible for any one individual to undertake all these 
roles and responsibilities, or for them to have an intimate knowledge of every single service user. 

Home Managers are assisted in their day to day role by a Deputy Manager who, at Downham Grange, has taken 
responsibility for  medication  delivery  and  is  the  Home’s  Clinical  Lead.  In  addition,  there  are  multiple  Heads  of 
Department  within  every home,  including  housekeeping  and  activity co-ordinators  and  all homes  must  operate 
with  a level of  trust in each  individual member of  staff  to fulfil their role to the best of  their ability.  At the risk  of 
repetition, the Company considers that it has been fundamentally let down in respect of Mrs Behrendt’s care by 
the acts and omissions of the NIC, who appears to have acted outside her own professional obligations despite 
the training provided to her. 

To  support  staff,  Home  Managers  offer  guidance  and  support  whenever  required  but  the  Company  does  not 
expect them to have an in-depth knowledge of each and every single service user within their home.  It is not for 
individual  Home  Managers  to  perform  all  roles  themselves.  The  Home  Manager  relies  upon  staff  to  relay  any 
issues requiring further consideration, and one of the purposes of the ’11 at 11’ meeting is to provide a forum for 
all staff, via their Heads of Department, to raise any issues for discussion with senior management. 

Each  home  is  supported  by  the  Company,  which  provides  centralised  support  to  all  managers  through  its 
Operations  and  Area  Managers.  The  Company’s  Operations  Managers  visit  each  home  on  a  regular  basis  to 
provide hands-on support and to identify and, if necessary, address, any developing concerns. 

Specifically  in  respect  of  Downham  Grange,  the  home’s  staffing  has  now  stabilised  following  events  of  the 
pandemic with the result that retention of staff has improved, which in turn has resulted in information relating to 
specific needs being retained within the business. 

We hope that  the  above  serves to address the Coroner’s  concerns,  but  should  further  information be  required 
please do not hesitate to contact the Company. 

Yours faithfully 

Eugene Nyamande 
Director of Compliance