John Duckenfield
18 Dec 2018 · Coroner David Urpeth · South Yorkshire (West)
The coroner's concerns
1. lack of accurate observation recording
“[TE f2'sely asserted he had taken observations of Mr [name redacted] in the presence of the family. Not only |, but safeguarding also, felt this assertion was dishonest.”
2. failure to record observations
“He failed to record observations he said he carried out despite accepting a need to do so.”
3. false claim about GP request
“Falsely asserted he was never asked to call a GP”
4. inadequate observation frequency
“The care home manager, {EN Said observations should have been taken daily and recorded but were not. Surprisingly therefore, she, asserted the care rendered was reasonable.”
5. inaccurate records
“Records kept by he home were inaccurate and misleading.”