Recurring concern

Failure to reliably monitor patient fluid balance

First to latest report 28 Aug 2013 — 22 Dec 2025

Reports that mention this concern
29
Times this concern has been raised
34
Stated actions linked to this concern
78

What this concern includes

Includes failures of the dedicated patient fluid-balance monitoring process, including failure to initiate, assess, measure, record or maintain monitoring, and delayed or incomplete monitoring when fluid status is clinically important.

What is not included
  • Excludes failures limited to recording fluid-balance information when monitoring itself was completed reliably.
  • Excludes generic clinical information, staffing or documentation deficiencies unless they directly cause failure of the patient fluid-balance monitoring process.
  • Excludes monitoring of other physiological measures unless the assertion specifically concerns patient fluid balance.
  • Excludes treatment or fluid-management decisions where no failure of fluid-balance monitoring is identified.

Reports and published responses 29 reports

See individual reports that have raised this concern, and the actions taken in response

  1. West London

    AI-generated summary

    Alaanuloluwa Joseph · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Master Alaanuloluwa Joseph died from sepsis, lung abscess and bacterial pneumonia at Great Ormond Street Hospital on 22 December 2015, after admission to Hillingdon Hospital earlier that day. Evidence indicated that fluid intake and output were not accurately monitored and recorded, despite the critical importance of fluid management in sepsis.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to accurately monitor fluid intake and output

    Wider context from the report

    “Evidence was heard that indicated that accurate monitoring and recording of fluid intake and output was not undertaken. Evidence was also heard that fluid management in sepsis is of critical importance. ”

    Source location

    Alaanuloluwa Joseph · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Wiltshire and Swindon

    AI-generated summary

    Christina Bernadette Withey · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Christina Bernadette Withey was an inpatient at Great Western Hospital when she suffered a stercoral perforation, leading to faecal peritonitis, sepsis and multi-organ failure, and died on 15 September 2015. The concerns included patient record-keeping and urine-output measurement, delays in reviewing patients whose condition had not improved, sepsis guidance, and the training of locum and other temporary staff.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to accurately measure urine output

    Wider context from the report

    “(1) The keeping of patient records in relation to a urine chart and the accurate measuring of output. ”

    Source location

    Christina Bernadette Withey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Surrey

    AI-generated summary

    Rhi anne Anoushka Florence BARTON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Rhi anne Barton developed severe abdominal pain and vomiting at 35 weeks of pregnancy after previous bariatric surgery and was later found to have a small bowel obstruction. She aspirated during induction of anaesthesia before surgery, developed severe physiological compromise and died in the early hours of 13 February 2015. The principal concerns included delays in investigation, diagnosis and surgical management, lack of consultant supervision, inadequate documentation and fluid monitoring, and insufficient consideration of surgical causes associated with previous bariatric surgery.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to accurately record routine observations, fluid balance and gastrointestinal losses

    Wider context from the report

    “4. Evidence was presented of poor documentation of routine observations and an incomplete fluid balance chart. No accurate records were kept with regard to fluid intake and urine output. It was not possible to assess the amount, frequency and volume of the vomitus. There was no evidence of diarrhoea despite a diagnosis of gastroenteritis. A urine dipstick was undertaken which revealed 4+ of glucose but no action was undertaken with regard to the finding. ”

    Source location

    Rhi anne Anoushka Florence BARTON · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Run an awareness campaign emphasising accurate fluid-balance documentation on Joan Booker Ward.

    Verbatim wording from the response

    “In addition, a directed audit of documentation of fluid balance was undertaken in Joan Booker Ward in May 2015; this highlighted inconsistencies in chart completion with overall balance totals rarely calculated. As a result, a campaign to raise awareness of the importance of correctly documenting fluid balance was undertaken and new training and competency assessments were introduced for staff who complete fluid balance charts. A redesigned fluid balance chart has been developed to facilitate accurate and complete recording of input and output details. A repeat, in depth, audit of fluid balance documentation will take place later this year following introduction and embedding of the new chart.”

    Source location

    2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
    Page 2 · response
    Published 1 June 2016

    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

    Introduce training and competency assessments for staff completing fluid-balance charts.

    Verbatim wording from the response

    “In addition, a directed audit of documentation of fluid balance was undertaken in Joan Booker Ward in May 2015; this highlighted inconsistencies in chart completion with overall balance totals rarely calculated. As a result, a campaign to raise awareness of the importance of correctly documenting fluid balance was undertaken and new training and competency assessments were introduced for staff who complete fluid balance charts. A redesigned fluid balance chart has been developed to facilitate accurate and complete recording of input and output details. A repeat, in depth, audit of fluid balance documentation will take place later this year following introduction and embedding of the new chart.”

    Source location

    2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
    Page 2 · response
    Published 1 June 2016

    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

    Develop a redesigned fluid-balance chart to support complete recording of patient input and output.

    Verbatim wording from the response

    “In addition, a directed audit of documentation of fluid balance was undertaken in Joan Booker Ward in May 2015; this highlighted inconsistencies in chart completion with overall balance totals rarely calculated. As a result, a campaign to raise awareness of the importance of correctly documenting fluid balance was undertaken and new training and competency assessments were introduced for staff who complete fluid balance charts. A redesigned fluid balance chart has been developed to facilitate accurate and complete recording of input and output details. A repeat, in depth, audit of fluid balance documentation will take place later this year following introduction and embedding of the new chart.”

    Source location

    2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
    Page 2 · response
    Published 1 June 2016

    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 a repeat in-depth audit of fluid-balance documentation after the new chart is introduced and embedded.

    Verbatim wording from the response

    “In addition, a directed audit of documentation of fluid balance was undertaken in Joan Booker Ward in May 2015; this highlighted inconsistencies in chart completion with overall balance totals rarely calculated. As a result, a campaign to raise awareness of the importance of correctly documenting fluid balance was undertaken and new training and competency assessments were introduced for staff who complete fluid balance charts. A redesigned fluid balance chart has been developed to facilitate accurate and complete recording of input and output details. A repeat, in depth, audit of fluid balance documentation will take place later this year following introduction and embedding of the new chart.”

    Source location

    2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
    Page 2 · response
    Published 1 June 2016

    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

    Introduce the Vitalpac electronic system for capturing patient observations across most inpatient areas.

    Verbatim wording from the response

    “An electronic system (Vitalpac) for capture of patient observations has been introduced into the Trust in the majority of inpatient areas. The Division have approached the developer of this system to see if modifications can be made to make it suitable for use in a maternity setting. This system can automatically calculate 'early warning scores' and issue alerts based on predetermined criteria.”

    Source location

    2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
    Page 2 · response
    Published 1 June 2016

    Open published response

  4. Leicester City and South Leicestershire

    AI-generated summary

    David Granville Oswald Hughes · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    David Granville Oswald Hughes was a patient at the Bradgate Unit who was found unresponsive on his bedroom floor at approximately 02:00 on 23 April 2014. The report identified concerns about failures in 15-minute observations, incomplete fluid balance charts, the lack of bedroom call bells, and nursing staff’s understanding of physical illness signs and symptoms.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to complete fluid balance charts consistently and accurately

    Wider context from the report

    “2. Fluid balance charts were not properly completed. There was no uniformity as to how or when staff would record fluid intake. Some staff would record fluid if they gave Mr. Hughes a drink. Some would record if they witnessed Mr Hughes drink it. Therefore, the fluid balance charts were rendered meaningless. ”

    Source location

    David Granville Oswald Hughes · Prevention of Future Deaths report
    Page 1 · concerns

    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

    Review the fluid balance chart and its relationship to the Trust Nutrition and Hydration Policy.

    Verbatim wording from the response

    “The lead Dietician for Adult Mental Health has been asked to review the fluid chart and its relationship to the Trust Hospital Nutrition and Hydration Policy. It is expected the review of the forms will be completed by the end of April 2016 and implementation will be supported by training to all clinical staff.”

    Source location

    David-Hughes-Response
    Page 2 · response
    Published 9 February 2016

    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

    Implement the reviewed fluid-balance documentation approach and support it with training for all clinical staff.

    Verbatim wording from the response

    “The lead Dietician for Adult Mental Health has been asked to review the fluid chart and its relationship to the Trust Hospital Nutrition and Hydration Policy. It is expected the review of the forms will be completed by the end of April 2016 and implementation will be supported by training to all clinical staff.”

    Source location

    David-Hughes-Response
    Page 2 · response
    Published 9 February 2016

    Open published response

  5. Brighton and Hove

    AI-generated summary

    Mrs. Evelyn KENNEDY · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record fluid intake and output

    Wider context from the report

    “(1) Once again my concerns involve the Acute Medical Unit (AMU). (2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. (4) She arrived unkempt. (5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care. (6) She felt cold and said she was cold. (7) She had been incontinent of faeces and had not been cleaned for some time. (8) She had no name wrist band. (9) In spite of known allergies she had no allergy wrist band. (10) In spite of falling regularly she had no falls risk wrist band. (11) She still had an IV cannula in place; this should have been removed after 72 hours. (12) Her daily catheter care bundle had not been completed for 3 days. (13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th. (14) Care plans were not completed for 17th, 18th, 19th or 20th. (15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th. (16) The handling assessment was not completed for 16th, 18th, 19th or 20th. (17) No food chart was completed for her entire time in AMU. (18) She had pressure damage to her hips and bottom. (19) No daily oral assessment was completed for her entire time on AMU. (20) She was not weighed. (21) The malnutrition tool was not completed. (22) Her bowel movements were not recorded. (24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart. PLUS (25) No personal care over the weekend of 18th and 19th. (26) No senior review over that weekend. (27) Not written up for her Sertraline, therefore not given (28) Not written up for any food supplements until 21st October. (29) She should have been specialled, but wasn’t. Once again AMU has been found to be chaotic and not fit for purpose. ”

    Source location

    Mrs. Evelyn KENNEDY · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Monitor documentation more closely and provide nurses with real-time feedback.

    Verbatim wording from the response

    “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:”

    Source location

    2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 7 May 2015

    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

    Review and condense Acute Medical Unit documentation into multidisciplinary paperwork that directs care and reduces duplication.

    Verbatim wording from the response

    “Extensive and complex work is also being undertaken to”

    Source location

    2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 3 · response
    Published 7 May 2015

    Open published response

  6. Surrey

    AI-generated summary

    Susanna Geraty · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Susanna Geraty, a previously fit and well 75-year-old woman, died after developing acute renal failure and hyperkalaemic cardiac arrest five days after surgery for a fractured tibia and fibula. The principal concerns were inadequate assessment, monitoring and recording of postoperative fluid balance, failure to respond promptly to family concerns or recognise her deteriorating condition, and an investigation report’s failure to consider dehydration as a possible cause of the acute renal failure.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to assess and monitor post operative fluid balance

    Wider context from the report

    “1. Failure to assess, monitor and record post operative fluid balance. ”

    Source location

    Susanna Geraty · Prevention of Future Deaths report
    Page 2 · concerns

    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 national-standard Early Warning Score paperwork and provide recurring staff training on deterioration recognition and fluid-balance monitoring.

    Verbatim wording from the response

    “Since this incident in 2012, SASH have implemented a number of improvements in the way that it records a patient’s fluid balance and in the way that it trains nursing staff with regards to recognising and acting on the identification of an acutely unwell patient and on monitoring post-operative fluid balance.”

    Source location

    2015-0026-Response-by-Surrey-Sussex-NHS-Trust
    Page 2 · response
    Published 27 January 2015

    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

    Provide Sepsis, Acute Kidney Injury and fluid-balance monitoring study days for ward nurses.

    Verbatim wording from the response

    “The CCOT have also started to provide a Sepsis/Acute Kidney Injury (AKI) and Fluid Balance Monitoring study day for ward nurses. The morning session consists of teaching sepsis theory followed by relevant case studies. The afternoon session concentrates on AKI theory and further case studies; the importance of fluid balance monitoring is also included in this session (appendix 3).”

    Source location

    2015-0026-Response-by-Surrey-Sussex-NHS-Trust
    Page 2 · response
    Published 27 January 2015

    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

    Deliver ward-based teaching on patient assessment, acute kidney injury and fluid balance, with further sessions planned during 2015.

    Verbatim wording from the response

    “Ward based teaching sessions have been held on Newdigate and Leigh wards in January 2015 by CCOT to educate the staff on patient assessment, AKI and fluid balance. These sessions were well received and more sessions are planned for staff during the year.”

    Source location

    2015-0026-Response-by-Surrey-Sussex-NHS-Trust
    Page 2 · response
    Published 27 January 2015

    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

    Restart ALERT courses covering deterioration recognition, acute kidney injury and fluid-balance charts.

    Verbatim wording from the response

    “ALERT™ courses (a multi-professional course to train staff in recognising patient deterioration and act appropriately in treating the acutely unwell) started again within the Trust last year, which includes a section on AKI and fluid balance charts. BEACH (Bedside emergency assessment course for health care staff) courses will start in April 2015, which will also stress the importance of fluid balance monitoring.”

    Source location

    2015-0026-Response-by-Surrey-Sussex-NHS-Trust
    Page 3 · response
    Published 27 January 2015

    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

    Start BEACH courses in April 2015, including fluid-balance monitoring training.

    Verbatim wording from the response

    “ALERT™ courses (a multi-professional course to train staff in recognising patient deterioration and act appropriately in treating the acutely unwell) started again within the Trust last year, which includes a section on AKI and fluid balance charts. BEACH (Bedside emergency assessment course for health care staff) courses will start in April 2015, which will also stress the importance of fluid balance monitoring.”

    Source location

    2015-0026-Response-by-Surrey-Sussex-NHS-Trust
    Page 3 · response
    Published 27 January 2015

    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 a Trust-wide audit of fluid-balance chart completion during 2015.

    Verbatim wording from the response

    “There is a Trust wide audit planned for 2015, to assess the completion of the fluid balance chart to monitor compliance.”

    Source location

    2015-0026-Response-by-Surrey-Sussex-NHS-Trust
    Page 3 · response
    Published 27 January 2015

    Open published response

  7. Manchester South

    AI-generated summary

    Gary Bradshaw · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Gary Bradshaw attended hospital with groin pain and kidney stones, later developed hyperparathyroidism and died during a hospital admission. The report identified concerns including delays and errors in diagnosis and testing, prescribing bendroflumethiazide before blood-test results, discharge before full investigation, inadequate escalation and fluid monitoring, and incomplete clinical records.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to keep fluid balance charts properly

    Wider context from the report

    “7. Fluid balance charts were not kept, or not kept properly, on various occasions during the in-patient stays (Stockport NHS Trust) ”

    Source location

    Gary Bradshaw · Prevention of Future Deaths report
    Page 1 · concerns

    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

    Improve fluid-balance documentation through contemporaneous recording, two-hourly chart review during intentional rounding, and checks before shift handover.

    Verbatim wording from the response

    “7. Fluid balance charts were not kept, or kept properly on various occasions during the in-patient stays. A conversation has been held with the ward manager of A11 with regard to the poor documentation on the fluid balance charts. The ward manager has reiterated with her staff the importance of contemporaneous record keeping and the importance of documenting each event as it happens, i.e. each time a patient has completed / consumed a drink, IV fluids are completed or changed or a patient has passed urine.”

    Source location

    2014-0232-Response-2
    Page 3 · response
    Published 15 May 2014

    Open published response

  8. Manchester South

    AI-generated summary

    Afifa Qaisar · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Afifa Qaisar was admitted to Tameside General Hospital on 23 June 2013 with collapse and confusion, initially diagnosed as meningitis with sepsis, and died at 20.30 hours the same day. Concerns included uncertainty about whether drugs recorded as given had actually been administered, unavailability of required resuscitation equipment, failure to notify the RMO, delays in platelet and Hb support, an inappropriate response to an apparently non-running saline infusion, and failure to commence fluid balance monitoring or catheterisation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to commence fluid balance charts for patients receiving intravenous fluids

    Wider context from the report

    “6. Despite the fact that this patient was receiving (apparently) i.v. fluids, at no time was a fluid balance chart commenced nor was the patient catheterised. The Ward manager agreed that both of these failings were unacceptable. ”

    Source location

    Afifa Qaisar · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  9. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Terrance O’Connell · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Terrance O’Connell was admitted to a care home for respite and later developed abdominal and penile pain with reduced catheter drainage. After a communication breakdown, he was not seen by clinical staff and was found extremely unwell two days later; he was diagnosed with sepsis from a urinary tract infection and died that evening. Concerns included failures in communication, monitoring of oral and urinary output, and clinical assessment, with the inquest conclusion stating that the infection went undiagnosed and untreated before hospital admission and that his condition was contributed to by neglect.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of direct monitoring of oral input and urinary output at the care home

    Wider context from the report

    “(2) There was no direct monitoring of his oral input and urinary output at the care home which would have provided further evidence in support of a urinary tract infection. ”

    Source location

    Terrance O’Connell · Prevention of Future Deaths report
    Page 1 · concerns

    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

    Review and revise the catheter-care and fluid-input/output procedures.

    Verbatim wording from the response

    “Notwithstanding this, the Monkstone House policy has been reviewed following Mr O’Connell’s death. The catheter care policy has been reviewed and all staff have now been given extra training. In addition, urinary input and output monitoring charts have been put in place for all clients. The Monkstone House Policy and procedures which are now in place have also been reviewed and approved by CSSIW, as documented in Monkstone House’s recent inspection report which took place in August 2013.”

    Source location

    2013-0218-Response-by-Gabbandco
    Page 2 · response
    Published 28 August 2013

    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

    Implement urinary input and output monitoring charts for all clients.

    Verbatim wording from the response

    “Notwithstanding this, the Monkstone House policy has been reviewed following Mr O’Connell’s death. The catheter care policy has been reviewed and all staff have now been given extra training. In addition, urinary input and output monitoring charts have been put in place for all clients. The Monkstone House Policy and procedures which are now in place have also been reviewed and approved by CSSIW, as documented in Monkstone House’s recent inspection report which took place in August 2013.”

    Source location

    2013-0218-Response-by-Gabbandco
    Page 2 · response
    Published 28 August 2013

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026