Care home asked to take action following death

A report by assistant coroner David Urpeth outlines a series of alleged shortcomings at Pexton Grange, in Pitsmoor, which he says emerged at an inquest into the death of John Duckenfield.

He says an employee, who is not named, ‘falsely asserted’ he had taken observations of Mr Duckenfield in the presence of his family – a claim Mr Urpeth says both he and the safeguarding team felt was ‘dishonest’.

His report adds that same member of staff also failed to record observations he said he carried out, despite accepting there was a need to do do, and ‘falsely asserted’ he was never asked to call a GP.

Mr Urpeth, who found records kept by the home were ‘inaccurate and misleading’, added: “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.”

The concerns are voiced in a ‘regulation 28 report’ sent last December to Brancaster Care Homes, which runs the home, but only just made public.

In it, Mr Urpeth writes: “In my opinion there is a risk that future deaths will occur unless action is taken.”

Mr Duckenfield was at Pexton Grange for three weeks following a fall which happened shortly before Christmas in 2017.

He was twice seen by a GP and treated for a chest infection during his stay, before being taken to Northern General Hospital, where he died on January 21, 2018.

Brancaster Care Homes said it was concerned at the coroner’s findings and the regulation 28 report, which it had responded to in detail in February.

“The clinical notes at the home show that there was regular interaction with Mr Duckenfield and include staff comments and interaction with his family. The notes also outline the care that Mr Duckenfield received,” the company added in a statement.

“A nurse giving evidence at the inquest confirmed that they carried out more observations than they recorded. We do not accept that there was any intention by the nurse to mislead.

“Our position is that Mr Duckenfield received reasonable care whilst he was at the home but we regret that daily observations were not always carried out or properly recorded. Mr Duckenfield was though receiving constant attention and assessment from the home.

“We are constantly reviewing our systems and striving to make them as robust as possible. Lessons have been learned from this investigation and acted upon which include new procedures regarding observations and record keeping with internal and external oversight to help ensure compliance.”

Pexton Grange was last inspected by the Care Quality Commission in November 2018 and was rated ‘good’ by the regulator.

Mr Urpeth recorded a narrative conclusion to the inquest.