Recurring concern

Unreliable recording of fluid balance information

First to latest report 6 Nov 2013 — 22 Dec 2025

Reports that mention this concern
46
Times this concern has been raised
50
Stated actions linked to this concern
87

What this concern includes

Includes failures of the dedicated fluid-balance recording process, including records of intravenous fluids, fluid intake and output, and food or fluid offers and consumption, where the recording deficiency impairs reliable assessment of fluid status.

What is not included
  • Excludes failures to administer prescribed fluids when the recording process itself is not deficient.
  • Excludes general poor maintenance of clinical or nursing records unrelated to fluid balance.
  • Excludes failures in fluid-balance assessment, escalation or treatment decisions unless they also involve unreliable fluid-balance recording.

Reports and published responses 46 reports

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

  1. Avon

    AI-generated summary

    Alan Christopher NIPPARD · 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

    Alan Christopher Nippard was admitted to hospital after a fall and developed a sacral pressure sore during his admission, followed by infection and deterioration. He died on 6 July 2022 after surgery was considered unsuitable. The report identified concerns that the pressure sore was preventable and that basic nursing care, including risk assessment, skin care, repositioning and personal care, was not provided adequately.

    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

    Poor completion of fluid balance charts

    Wider context from the report

    “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with. There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking. It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired. That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight. I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including: • That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly. • On the MAU he did not have his risk assessment done within 6 hrs as it should have been. • It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress. • Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay. • Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved. • The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed. • Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t. • On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation • Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all. • It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been. • When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly. • It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved • There was no evidence of the use of 2 sliding sheets to assist with moving him. • On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all. • Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable. • Fluid balance charts were poorly completed. • He wasn’t weighed which would have assisted with managing his oedema. • Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care. I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team. ”

    Source location

    Alan Christopher NIPPARD · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  2. Milton Keynes

    AI-generated summary

    Alexander Shone BLEWITT · 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

    Alexander Shone Blewitt died at Milton Keynes University Hospital on 11 July 2022 after returning to the emergency department with faecal incontinence and abdominal pain, following an earlier visit where he had been referred from an urgent care centre. A possible acute abdomen was confirmed by CT, and he suffered a cardiac arrest before surgery. Concerns included inaccurate communication of important symptoms and treatment information, inadequate clinical recording, and the absence of reliable records of intravenous fluids administered in the emergency department.

    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 effective, reliable recording of intravenous fluids administered in the emergency department

    Wider context from the report

    “[1] At the time of Mr Blewitt's death there was no effective, reliable recording of intravenous fluids administered to patients in the emergency department. That in my view has potential to represent a threat to the safety and lives of patients suffering with a wide variety of different conditions. The author of the SI report who attended to give evidence did not, at the time of request 8 months later, was unable to demonstrate that the Trust had remedied that. ”

    Source location

    Alexander Shone BLEWITT · 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 a short-infusion electronic fluid order that remains visible until administration or discharge.

    Verbatim wording from the response

    “This issue was raised with Oracle Cerner and we developed a distinct ‘short infusion’ order. In this scenario, the prescription remains a planned administration and does not ‘grey out’ on the chart at the expected time of completion. The ‘short infusion’ order remains visible as due until it is administered, or when the patient is discharged from the clinical encounter. It does not expire at a timepoint related to the time of prescription and/or the calculated time of completion of administration. It has been specifically designed for use when prescribing fluids for infusion over a short duration (i.e., an hour or less).”

    Source location

    Response from Milton Keynes University Hospitals
    Page 3 · response
    Published 23 June 2023

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    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

    Write to registered Emergency Department staff highlighting the case, referral-note review, electronic prescribing, fluid documentation, short-infusion orders and timely sepsis treatment.

    Verbatim wording from the response

    “The Chief Nurse and I will be writing to all registered staff in the ED to highlight the key elements of Mr Blewitt’s case, and to remind them of the issues referenced in this letter:”

    Source location

    Response from Milton Keynes University Hospitals
    Page 8 · response
    Published 23 June 2023

    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

    The electronic prescribing expiry issue was not relevant to the patient's case, although fluid administration documentation was poor.

    Verbatim wording from the response

    “In Mr Blewitt’s case, documentation around fluid administration is poor but it does not seem that this specific eCare related issue – which I think was introduced into evidence at the Inquest - was relevant.”

    Source location

    Response from Milton Keynes University Hospitals
    Page 3 · response
    Published 23 June 2023

    Open published response

  3. East London

    AI-generated summary

    George Frederick Kearsey · 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

    George Frederick Kearsey sustained injuries in a fall at home, was admitted to hospital, developed aspiration pneumonia, and died on the evening of 8 June 2022. Concerns included inconsistent administration of IV fluids, missing fluid balance charts, poorly maintained clinical records, and inadequate review of fluid monitoring during consultant-led ward rounds.

    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 put fluid balance charts in place

    Wider context from the report

    “2. Contrary to Trust policy, fluid balance charts were not put in place to assess Mr Kearsey’s fluid intake and output. ”

    Source location

    George Frederick Kearsey · Prevention of Future Deaths report
    Page 2 · 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

    Poor maintenance of clinical records of fluid administration

    Wider context from the report

    “3. Clinical records were poorly maintained, resulting in an unclear picture of fluid administration. ”

    Source location

    George Frederick Kearsey · 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

    Conduct and continue unannounced cross-site fluid-management audits on every COTE ward, monitoring Careflow Vitals recording and appropriate follow-up.

    Verbatim wording from the response

    “• Cross site audits have been completed on COTE (Care of the Elderly) wards on a random basis to understand a cross section of compliance with fluid management with no notice given to the ward in advance of the audit. The audits capture patients who are on fluid restriction, patients requiring oral and intravenous hydration, parenteral nutrition and output monitoring, whether the intake and output is entered on Careflow Vitals and appropriate action taken as necessary. The audits were completed by senior nursing teams (Matrons, Ward Managers, Practice Development Nurses).”

    Source location

    Response from Barking, Havering and Redbridge University Hospitals
    Page 1 · response
    Published 24 February 2023

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    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 peer fluid-monitoring audits between COTE wards and share results through governance meetings and daily huddles.

    Verbatim wording from the response

    “• Peer audits are being undertaken - The first phase of the audits has been completed. The nursing staff on all wards have been informed of the expectation for fluid monitoring and recording this on Careflow Vitals. We have also introduced peer audits where ward teams will conduct random audits on other COTE wards for the next 6 months. The format of these audits will mirror those conducted by the wards. The feedback from these audits will be shared with the matron and ward manager of that area and relevant action taken, if required. An example is if a patient is on fluid restriction and their fluid intake has not been recorded on careflow vitals. This can have an adverse effect on the patient’s treatment. The ward manager will discuss the importance of fluid management and monitoring with staff.”

    Source location

    Response from Barking, Havering and Redbridge University Hospitals
    Page 2 · response
    Published 24 February 2023

    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 nursing staff with Careflow Vitals training and one-to-one fluid-monitoring support.

    Verbatim wording from the response

    “• Nursing staff have received additional training on Careflow vitals to reinforce the importance of staff compliance with the Trust policy on the completion of fluid monitoring. In addition, nursing staff have had 1:1 sessions with matrons and practice development nurses. Since the implementation of the audits, an improvement has been noted in fluid balance monitoring. For example, on 15 February 2023, Clementine A only scored 70% compliance. The gaps were discussed and addressed immediately with the nursing teams. This improved the compliance on Clementine A, with audits now showing 100% compliance.”

    Source location

    Response from Barking, Havering and Redbridge University Hospitals
    Page 2 · response
    Published 24 February 2023

    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

    Train medical staff to access fluid balances in Careflow Vitals and discontinue completion of paper fluid charts.

    Verbatim wording from the response

    “• We identified that some medical staff were not familiar with using Careflow Vitals to access patients’ fluid balance. Face to face training, by the Careflow team has now been provided for all medical staff, to ensure they are all aware of how to access the fluid balance on Careflow Vitals. Medical staff were all made aware that paper fluid charts will not be completed in the future.”

    Source location

    Response from Barking, Havering and Redbridge University Hospitals
    Page 2 · response
    Published 24 February 2023

    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

    Carry out a clinical safety assessment to identify and mitigate hazards affecting entry or viewing of fluid-balance data.

    Verbatim wording from the response

    “In addition to the above a Clinical Safety Assessment is to be carried out by the end of April 2023. The purpose of the assessment is to identify any hazards, risks or issues to mitigate any issues of not being able to enter data or view fluid balance records. Thirteen staff completed the clinical safety (CS) officer training on the 29th /30th March. The CS role is in the recruitment process and will be interviewed for on the 18th April 2023.”

    Source location

    Response from Barking, Havering and Redbridge University Hospitals
    Page 3 · response
    Published 24 February 2023

    Open published response

  4. Norfolk

    AI-generated summary

    Janice HOPPER · 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

    Janice HOPPER was discharged from hospital to a care home on 31 December 2021, became unwell in January 2022, was admitted to hospital, and died on 12 February 2022. Concerns included inaccurate and inadequately reviewed care plans, failures to monitor blood glucose, food and fluid intake, and the administration of Morphine Sulphate as a matter of course despite instructions that it was to be given only as required. The inquest recorded the medical cause of death as Alzheimer's Dementia, Chronic Kidney Disease and Type 2 Diabetes Mellitus, with a conclusion of natural causes.

    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

    Inaccurate recording of food intake

    Wider context from the report

    “9. There were concerns about Mrs Hopper's food intake. It is not clear from the evidence that the amount stated in the records as being consumed was accurate. For instance, on several occasions she was noted to have consumed large amounts of fluid in one go and to have eaten more than one meal within a short space of time. ”

    Source location

    Janice HOPPER · Prevention of Future Deaths report
    Page 2 · 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 record fluid intake directly by the estimating staff

    Wider context from the report

    “8. The amount of fluid intake was not always recorded in the notes by the staff who had estimated the amount consumed but relayed to another member of staff who would complete the records. ”

    Source location

    Janice HOPPER · 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

    Operate a hydration-monitoring system using first-four-week fluid charts, shift-based hydration trolleys, millilitre recording and daily senior review of charts and electronic records.

    Verbatim wording from the response

    “All residents’ care plans are developed with the individual, information gained from the residents’ pre admission assessment and information gained from the resident and their family allows us to gain information regarding what their fluid intake has been like and also through fluid charts for the first four weeks, allows us to monitor fluid intake. Hydration trolleys are in effect at the home, one each shift one person is allocated to be responsible for ensuring that residents’ fluid intake is monitored and documented accurately. This was discussed at the care plan training and how to accurately record fluid intake. All staff are required to ensure that they record intake in millilitres, “mls” in all entries so that the electronic care record system automatically picks up the intake and calculates it.”

    Source location

    Response from Runwood Homes
    Page 2 · response
    Published 1 December 2022

    Open published response

  5. Berkshire

    AI-generated summary

    Frederick Robert Peter King · 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

    Frederick Robert Peter King was a resident at Birchwood Care Home and died in hospital on 9 September 2021 from an acute kidney injury caused by dehydration, with frailty and vascular dementia contributing to his death. The concerns included inadequate fluid provision, incomplete care records, and the absence of a care-home manager on the ground in the three days before his death.

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    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 maintain complete records of fluid provision and pad status

    Wider context from the report

    “(2) Inadequate record keeping in the Birchwood Care made it difficult to obtain the relevant records for the Inquest and the records obtained were incomplete for example in terms of what recording timings of fluid provision, whether pads were wet/dry and also family concerns regarding health were not recorded and conveyed. ”

    Source location

    Frederick Robert Peter King · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    The provider has taken sufficient action to mitigate risks and prevent future deaths.

    Verbatim wording from the response

    “We sent an urgent letter to the provider West Berkshire Council to confirm CQC had received the regulation 28 report and asked them to set out in writing evidence of the actions they had taken to date following this death and any additional action they intended to take in response to the prevention of future death report. We received a detailed response from the provider. We are satisfied the provider has taken sufficient action according to section 6 of the regulation 28 report to mitigate risks to people and prevent future deaths.”

    Source location

    Response from Care Quality Commission
    Page 2 · response
    Published 21 November 2022

    Open published response

  6. Lincolnshire

    AI-generated summary

    Lilian SHEARING · 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

    Lilian SHEARING died in Lincoln County Hospital on 29 September 2019 after admission for unrelated medical treatment. Before her hospital admission, poor fluid intake was recorded at her care home, but no risk assessment was undertaken and omissions were made from the fluid intake chart; her intake was later estimated to have been approximately 25% of the expected level due to dehydration.

    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 accurately

    Wider context from the report

    “Upon admission on 11th July 2019 to your care home it was recorded at handover the deceased had a poor fluid intake. Despite this no risk assessment was undertaken. Omissions were also made from the fluid intake chart. It was conceded at Inquest today by your regional manager that the deceased's fluid intake was approximately 25% of where it should have been before her admission to hospital on 23rd August 2019 due to dehydration. Policies/assessments were clearly not in place to cover this eventuality. What are your current policies re risk assessments for fluid and nutritional intake? ”

    Source location

    Lilian SHEARING · 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

    Maintain ongoing staff training on nutrition, hydration, and responding to declining food or fluid intake.

    Verbatim wording from the response

    “Training It is three years since Mrs LS death and the monitoring and auditing processes within all Tanglewood homes has been enhanced significantly. Throughout the pandemic, work has been ongoing to continue to provide essential training. A new platform for e-learning was introduced which enabled team members, both newly employed and established, to access ongoing training throughout this period. There has been a continued focus on the importance of nutrition and hydration and how we support residents in all stages of their later life and what we can do in the event of the individual declining adequate nutritional and fluid intake required to sustain life. A care plan manager has been employed to oversee the care plans and content in all homes ensuring the standard of documentation is consistent, this person also provides training to all care teams to ensure the process is understood.”

    Source location

    Response from Tanglewood Cloverleaf Care Home
    Page 1 · response
    Published 5 October 2022

    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 amend the Nutrition and Hydration policy to cover intake recording, refusals, fluid targets, and discussions with clinicians and families.

    Verbatim wording from the response

    “Policy & Procedure We have reviewed the content of the Nutrition & Hydration policy and amended the content to include current practice of monitoring and recording all intake (see appendix 1), how we support the resident who may be reluctant to accept food and fluids especially at end of life, and the importance of recording if a resident declines assistance or intervention. What we do if a residents daily fluid target appears excessive and is not consistently achieved over a 7-day period and how we manage and record the discussions with the GP and family members in relation to this.”

    Source location

    Response from Tanglewood Cloverleaf Care Home
    Page 1 · response
    Published 5 October 2022

    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

    Embed admission safeguards requiring risk assessments, daily charts, documented communications, timely referrals, and updates to residents and representatives.

    Verbatim wording from the response

    “• Ensure that any risk assessments required are completed to ensure minimal risk to the person”

    Source location

    Response from Tanglewood Cloverleaf Care Home
    Page 2 · response
    Published 5 October 2022

    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

    Continue face-to-face staff training on care documentation and recording offered or declined nutrition and fluids.

    Verbatim wording from the response

    “• Ongoing face-to-face staff training within the homes to embed the importance of maintaining records and documentation to provide evidence of care provided”

    Source location

    Response from Tanglewood Cloverleaf Care Home
    Page 2 · response
    Published 5 October 2022

    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

    Staff cannot force residents to take food or fluids when they refuse, but must record the refusal and intake.

    Verbatim wording from the response

    “• Ongoing staff training within the homes to ensure that all nutritional and fluid intake is recorded even if declined as we are unable to force residents to take food & fluids if they refuse”

    Source location

    Response from Tanglewood Cloverleaf Care Home
    Page 2 · response
    Published 5 October 2022

    Open published response

  7. West Yorkshire Eastern

    AI-generated summary

    Mark Anthony Athias · 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

    Mark Anthony Athias had multiple physical and mental health issues, including recurring urinary infections and problems with a long-term catheter. After difficulties with his catheter on 2 July 2021, he was admitted to hospital, where his condition deteriorated and he died on 6 July 2021. Concerns included a lack of sterile replacement catheters, inadequate monitoring records, and a missing handover record, with risks arising from deficient record keeping.

    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 managers to detect inadequate monitoring records

    Wider context from the report

    “2. The catheter care plan had identified the need for his fluid intake and output to be monitored. The contemporaneous records kept were, however, inadequate. This hindered any assessment of his urinary problems. The managers in the nursing home had not noticed the inadequacy of such records. ”

    Source location

    Mark Anthony Athias · 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

    Inadequate contemporaneous records of fluid intake and output

    Wider context from the report

    “2. The catheter care plan had identified the need for his fluid intake and output to be monitored. The contemporaneous records kept were, however, inadequate. This hindered any assessment of his urinary problems. The managers in the nursing home had not noticed the inadequacy of such records. ”

    Source location

    Mark Anthony Athias · 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

    Deliver catheter-care refresher training and shared learning on fluid-intake recording and alternative catheter access routes.

    Verbatim wording from the response

    “Copperfields delivered shared learning with the nursing staff following Mr Athias' death which highlighted the other avenues available to access catheters in the community. In addition, following the implementation of the EMAR system at Copperfields in February 2022, all staff were provided with several weeks of EMAR training and have access to 24 hours a day support from the EMAR team. The nurses and management team have been trained to review the stock”

    Source location

    2022-0024-Response-from-Exemplar-Health-Care_Published
    Page 2 · response
    Published 31 January 2022

    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

    Digitise EQA governance and establish team-leader accountability, daily management reviews, clinical walkarounds, take-twenty meetings and electronic quality-assurance tracking.

    Verbatim wording from the response

    “In addition to these management changes, specific steps have also been taken to ensure greater management overview, and quality assurance, of record keeping and documentation. During Mr Athias' residence at Copperfields the relevant governance processes (EQA- External Quality Assurance) were paper based. However, the majority of the EQA processes have now been moved to a digital platform.”

    Source location

    2022-0024-Response-from-Exemplar-Health-Care_Published
    Page 3 · response
    Published 31 January 2022

    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 monthly audits of supplementary and care files, with findings discussed with unit managers.

    Verbatim wording from the response

    “9. Copperfields has implemented monthly auditing of supplementary and care files and findings are discussed with individual unit managers.”

    Source location

    2022-0024-Response-from-Exemplar-Health-Care_Published
    Page 5 · response
    Published 31 January 2022

    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 workshops and coaching on creating, implementing and monitoring unambiguous care plans and comprehensive records across all service users.

    Verbatim wording from the response

    “Further workshops and coaching sessions have also been undertaken by various experienced Quality Managers in order to support staff to create, implement and monitor more thorough and unambiguous care plans. In the first instance this support was focussed on the documentation for service users who utilised catheters, however the workshops have now been undertaken in relation to all service users and included general sessions on record keeping and documentation. You heard evidence from Ms ████████ that significant management change has now taken place at Copperfields since Mr Athias' death. A new Registered Home Manager and new Clinical Nurse Manager are now in place. In addition, a second full time Clinical Nurse Manager and a full time Head of Care have been employed.”

    Source location

    2022-0024-Response-from-Exemplar-Health-Care_Published
    Page 3 · response
    Published 31 January 2022

    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

    Existing management oversight, quality assurance and governance processes are considered sufficient to ensure records are kept, retained and reviewed for trends.

    Verbatim wording from the response

    “I have detailed above the relevant management structure changes and quality assurance systems in place to ensure that all record keeping is appropriate and accurate. In summary:”

    Source location

    2022-0024-Response-from-Exemplar-Health-Care_Published
    Page 4 · response
    Published 31 January 2022

    Open published response

  8. Manchester North

    AI-generated summary

    Nichola Jane Lomax · 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

    Nichola Jane Lomax had a long history of an eating disorder and attended hospital several times in 2020 with severe malnutrition and electrolyte imbalance. She died on 3 August 2020 after delays and failings involving hospital treatment, specialist referral, communication, monitoring, nutritional care and access to appropriate services. The report identified concerns about inadequate eating-dis disorder training, access to specialist advice, referral criteria, critical services, community monitoring, nursing care and investigation of deaths.

    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 maintain nutrition and fluid charts

    Wider context from the report

    “6) Nursing Input and Recording For NCA Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information. ”

    Source location

    Nichola Jane Lomax · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  9. Norfolk

    AI-generated summary

    Ben Buster KING · 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

    Ben Buster KING was detained under the Mental Health Act at Jeesal Cawston Park and died in hospital on 29 July 2020 after becoming unwell following respiratory problems and receiving sedative medication. The inquest identified concerns including failure to diagnose obesity hypoventilation syndrome, inadequate consideration of promethazine, failure to recognise the seriousness of a life-threatening situation, and wider care, observation, record-keeping and hospital communication issues.

    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 the care recording system to support accessible and complete food and fluid intake records

    Wider context from the report

    “8. JCP used the Pandora software system, (company Directors for Pandora are the same as for JHL and JRCSL) which is still used at the residential homes owned by JHL and JRCSL. Concerns were raised at the inquest in respect of this software system in that not all policies and documents were available to staff on the IPads provided, some of the documents were unwieldy and difficult to read (eg Personal Healthcare Plan), the Dietician recommended use of paper records in respect of Food and Fluid intake as these would be more accessible to staff and encourage the documents to be completed or in the alternative providing for the records on Ipads to be more easy to access and complete ”

    Source location

    Ben Buster KING · 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

    Develop and improve the Pandora information system through a staff user group.

    Verbatim wording from the response

    “6. The MD and members of the GAT have access to every resident’s care file, we also have access to a whole range of information on each resident, all of which we can access remotely. The GAT carries out regular service reviews and unannounced inspections. Where there are deficiencies, the GAT will work with the Registered Manager to correct these deficiencies which may include report writing, care planning, risk assessments and healthy living plans. As an example, the GAT recently found inconsistencies in recording of information on Pandora, with some confusion as to record entries. This led to the establishment of a Pandora User Group, to work with homes to improve consistency of recording and content.”

    Source location

    2021-0250-Response-from-Jeesal-Residential-Care-Services_Published
    Page 3 · response
    Published 23 July 2021

    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

    A paper-based care system is considered detrimental because it would undermine remote monitoring, statistical analysis and a whole-system approach.

    Verbatim wording from the response

    “We note the suggestion by the Dietician to have a paper-based system. We am resistant to this as this will undermine my ability and the ability of GAT and external colleagues to monitor remotely. I consider a two-system approach to be detrimental when trying to achieve a whole system approach to care and support. Unlike a hospital where the patients are in one place, our residential services are spread across the county and as such, while physical attendance at a home is important, so too is remote access. In addition, the Pandora system allows us to carry out statistical analysis and monitor trends.”

    Source location

    2021-0250-Response-from-Jeesal-Residential-Care-Services_Published
    Page 4 · response
    Published 23 July 2021

    Open published response

  10. Blackpool and the Fylde

    AI-generated summary

    Douglas OWENS · 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

    Douglas Robert Owens developed acute cardiac failure, hypotension, aspiration pneumonia and multi-organ failure after cataract surgery, treatment for raised intraocular pressure, ongoing eye pain and painful urinary retention. He died in intensive care on 7 July 2018. Concerns included arrangements for urgent ophthalmic transfer, specialist assessment, monitoring and review of deterioration, fluid documentation, and recording medication doses.

    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 prescription and fluid balance charts for prescribed fluids

    Wider context from the report

    “(5)That the evidence disclosed the fact that, whilst fluids had been prescribed, no prescription chart or fluid balance chart had been completed. Unless action is taken to ensure the completion of applicable documentation, the lives of patients may be put at risk. ”

    Source location

    Douglas OWENS · 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

    Conduct regular Emergency Department spot audits and huddles to verify NEWS2 recording, prompt escalation and completion of fluid charts.

    Verbatim wording from the response

    “In the interim, the Head of the Emergency Department and the Matron will ensure senior clinical staff will undertake regular spot audits / huddles, to ensure all patients in the ED have their NEWS2 score recorded correctly, that any changes in score are acted upon promptly and that fluid charts are completed correctly and acted upon promptly. The ED complete a Consistency in Care Audit daily, where 40 patients’ notes (approximately 20% of all patients daily) are reviewed in real time and this includes a review of the NEWS 2 and fluid balance. This is used to monitor the compliance and manage any inconsistencies in care at the time. Additionally the ED undertakes an intentional round, where all patients who have been in the department for longer than 4 hours, are reviewed by the EPIC (Emergency Physician in Charge) to ensure that appropriate plans of care are in place.”

    Source location

    2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
    Page 3 · response
    Published 3 December 2020

    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

    Complete daily real-time Consistency in Care Audits reviewing NEWS2 and fluid-balance compliance and manage identified inconsistencies.

    Verbatim wording from the response

    “In the interim, the Head of the Emergency Department and the Matron will ensure senior clinical staff will undertake regular spot audits / huddles, to ensure all patients in the ED have their NEWS2 score recorded correctly, that any changes in score are acted upon promptly and that fluid charts are completed correctly and acted upon promptly. The ED complete a Consistency in Care Audit daily, where 40 patients’ notes (approximately 20% of all patients daily) are reviewed in real time and this includes a review of the NEWS 2 and fluid balance. This is used to monitor the compliance and manage any inconsistencies in care at the time. Additionally the ED undertakes an intentional round, where all patients who have been in the department for longer than 4 hours, are reviewed by the EPIC (Emergency Physician in Charge) to ensure that appropriate plans of care are in place.”

    Source location

    2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
    Page 3 · response
    Published 3 December 2020

    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