Recurring concern

Failure to reliably monitor patients' weights

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First reported 13 Jan 2014•Latest report 23 Jun 2025

Definition

What this concern includes

Includes failures of the patient-weight monitoring process, including missed or irregular weighing, incomplete recording, and inability to obtain weight measurements safely or reliably where weight is needed for clinical monitoring or weight-dependent treatment.

Not included

Excludes medication monitoring failures where patient weight is not the identified control.
Excludes generic clinical documentation or record-keeping deficiencies that do not specifically concern recording patient weights.
Excludes nutritional assessment, weight-loss recognition or treatment decisions where no failure of patient-weight measurement or monitoring is identified.
Excludes unrelated weighing processes, such as equipment, goods or public-road measurements.

Reports: 14
Individual concerns: 15
Date range: 2014–2025
Stated actions: 13

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care3

49 Marine Avenue Surgery1

Barking, Havering and Redbridge University Hospitals NHS Trust1

Bedfordshire Hospitals NHS Foundation Trust1

Brunswick Ward at Lindridge1

Government Legal Department1

HM Prison and Probation Service1

Jeesal Akman Care Corporation Limited1

Jeesal Holdings Limited1

Jeesal Residential Care Services Limited1

Leeds City Council1

Leeds Community Healthcare NHS Trust1

Moorbridge1

Moorfield House Surgery1

National Institute for Health and Care Excellence1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

30 Oct2015
East London
Concerns raised1
1. Failure to weigh patients before commencing heparin infusion
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Introduce an unfractionated-heparin chart and weight-based guideline with six-hour APTT checks and consultant escalation for abnormal results at extreme weights.
  Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completed
Respondent positions 1
1. Position
  Weight-based dosing, six-hour APTT checks and conditional haematology advice are considered sufficient safeguards without routine consultation for extreme patient weights.
  Stated by Barking, Havering and Redbridge University Hospitals NHS TrustExisting arrangements considered sufficient
AI-generated summary

Mary Catherine Bloom · 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

Mary Catherine Bloom, who had dementia and reduced oral intake, was admitted with probable left-leg ischaemia and died in hospital on 4 February 2014. Concerns included failures to record her weight, consult haematology, obtain baseline and follow-up blood tests, and make the heparin administration guidance sufficiently visible. There was also no discussion with her next of kin before a DNAR order was placed.

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 weigh patients before commencing heparin infusion
Wider context from the report
“1. There was a failure to comply with the Trust’s policy relating to the administration of heparin, by failing to weigh Mrs Bloom prior to the commencing the infusion of heparin. 2. There was a failure to consult a haematologist before the infusion of heparin in view of Mrs Blooms’ very low weight of 30 kilograms. Again, this is required by the Trust policy. 3. It was not possible to take baseline bloods before the commencement of heparin, however, attempts should have been made to retake bloods after hydration had commenced. The Trust policy requires baseline bloods to be taken and for the APTT to be checked after 6 hours. ”
Source location
Mary Catherine Bloom · 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
Introduce an unfractionated-heparin chart and weight-based guideline with six-hour APTT checks and consultant escalation for abnormal results at extreme weights.

Verbatim wording from the response
“In your letter you acknowledge receipt of three new policies that have been put in place by the Trust following the inquest and the new chart that has been introduced for the administration of unfractionated heparin. You have however raised further concerns with regards to the new Trust guidelines that have removed the inquest and the new chart that has been introduced for the administration of unfractionated heparin. You have however raised further concerns with regards to the new Trust guidelines that have removed the requirement for a haematologist to be consulted where a patient is at the extremes of weight. The reasoning for this decision is as follows.”

Source location
2015-0417-Response
Page 1 · response
Published 30 October 2015
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Weight-based dosing, six-hour APTT checks and conditional haematology advice are considered sufficient safeguards without routine consultation for extreme patient weights.

Verbatim wording from the response
“The Trust’s new policy is for a weight based bolus and then a weight based infusion the latter within weight ranges. Even with a patient of 25kg the infusion would be at 20iu/kg/hr which is a very reasonable infusion rate and in line with recognised dosage rates even at this weight. The APPTT must be checked at 6 hours and this allows the dose to be adjusted within recognised time intervals. We therefore feel that the safeguards are in place as we have moved to an entirely weight based formulation. As an extra safeguard the guideline, following the concerns you raised, now also states that if the APPTT at 6hrs is outside the expected range then the Consultant Haematologist should be contacted for further advice in those patients at the extreme ends of the weight ranges i.e. <41kg and >90kg.”

Source location
2015-0417-Response
Page 1 · response
Published 30 October 2015
Open published response
7 May2015
Brighton and Hove
Concerns raised1
1. Failure to weigh the patient
This report raised 24 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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 weigh the patient
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
17 Nov2014
West Yorkshire (East)
Concerns raised2
1. Failure to regularly and fully record residents' weights
2. Failure to regularly monitor residents' weights
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mrs Gladys Smith · 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 Gladys Smith died while resident at a care home; the supplied text does not provide further circumstances of her death. The concerns included failures in repositioning, bruise and wound monitoring, falls assessment, weight and nutrition monitoring, dementia care, and delays or gaps in district nursing wound documentation and referral. The report also identified a lack of comprehensive national guidance on wounds and ulcers caused by impact injuries.

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 regularly and fully record residents' weights
Wider context from the report
“(e) Between January and June 2012 Mrs Smith lost a total of 28lbs in weight. Mrs Smith's weight was neither regularly monitored nor regularly and fully recorded. In the circumstances, Care Home staff should ensure that there is regular monitoring and appropriate recording of residents' weights'; ”
Source location
Mrs Gladys Smith · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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 regularly monitor residents' weights
Wider context from the report
“(e) Between January and June 2012 Mrs Smith lost a total of 28lbs in weight. Mrs Smith's weight was neither regularly monitored nor regularly and fully recorded. In the circumstances, Care Home staff should ensure that there is regular monitoring and appropriate recording of residents' weights'; ”
Source location
Mrs Gladys Smith · Prevention of Future Deaths report
Page 1 · concerns
Open source report
13 Jan2014
County Durham and Darlington
Concerns raised1
1. Failure of doctors and nurses to routinely weigh patients
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Zeeyad Hamadi · 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

Zeeyad Hamadi was a prisoner at HMP Frankland who became unwell, was diagnosed with Hodgkins Lymphoma, and deteriorated while arrangements were made to transfer him to a London hospital for private chemotherapy. Concerns included inadequate weighing and medical record keeping, limited communication between prison and hospital staff, unclear funding and transfer arrangements, and the absence of a system or responsible point of contact to manage the transfer, contributing to delay.

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 of doctors and nurses to routinely weigh patients
Wider context from the report
“(1) The evidence disclosed that the deceased had not been weighed at the times of medical appointments and a history of weight loss would have been a useful diagnostic tool. Not all medical consulting rooms at HMP Frankland had scales to do so and doctors/nurses did not routinely weigh patients. ”
Source location
Zeeyad Hamadi · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to weigh patients before commencing heparin infusion

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to weigh the patient

Concerns raised2

Failure to regularly and fully record residents' weights

Failure to regularly monitor residents' weights

Concerns raised1

Failure of doctors and nurses to routinely weigh patients

Actions described in response 1

Respondent positions 1