Recurring concern

Unreliable recording of fluid balance information

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First reported 6 Nov 2013•Latest report 22 Dec 2025

Definition

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.

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: 46
Individual concerns: 50
Date range: 2013–2025
Stated actions: 87

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 Care6

University Hospitals Sussex NHS Foundation Trust4

Blackpool Teaching Hospitals NHS Foundation Trust3

Care Quality Commission3

NHS England3

Ashford and St Peter'S Hospitals NHS Foundation Trust2

General Medical Council2

Greater Manchester Mental Health NHS Foundation Trust2

Pennine Acute Hospitals NHS Trust2

Royal College of Obstetricians and Gynaecologists2

Stockport NHS Foundation Trust2

Academy of Medical Royal Colleges1

Amberley Hall Care Home1

Athena Care Homes (UK) Limited1

Barking, Havering and Redbridge University Hospitals NHS Trust1

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.

14 Jun2017
West London
Concerns raised1
1. Failure to accurately record fluid intake and output
This report raised 1 other concern. 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

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 record 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
13 Apr2017
Preston and West Lancashire
Concerns raised1
1. Failure to complete the fluid balance chart
This report raised 13 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

Michael John NEWELL · 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

Michael John Newell died following an admission involving haemorrhage, decompensated liver failure and associated coagulopathy. Concerns included a lack of awareness among emergency and surgical staff of the significance of his liver failure, inadequate recognition and treatment of hypovolaemia, lack of consultant ENT input, weaknesses in the mortality review process, and nursing documentation and management 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 to complete the fluid balance chart
Wider context from the report
“(5) the conduct of the Nurse in charge of the ward of making no notes after her presence at a peri-arrest, neither seeking or obtaining any direction from the medical team as to future management, not directing any further resuscitation in accordance with documented medical plans in the notes and lack of completion of the fluid balance chart would suggest that the Trust's procedures for determining which nurse clinicians may lead a nursing shift should be reviewed. ”
Source location
Michael John NEWELL · Prevention of Future Deaths report
Page 1 · concerns
Open source report
7 Apr2017
Wiltshire and Swindon
Concerns raised1
1. Failure to keep patient records relating to urine charts
This report raised 4 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

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 keep patient records relating to urine charts
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
8 Mar2017
Manchester City
Concerns raised1
1. Inaccurate and incomplete fluid balance charts
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 Kathleen Cooper · 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 Kathleen Cooper, aged 73, underwent elective sigmoid colectomy and later deteriorated, suffering an intra-operative cardiac arrest during emergency surgery on 11 July 2016. The report identified medical and nursing neglect, including communication and record-keeping failures, inadequate supervision, inaccurate observations and early warning scores, delayed tests and treatment, and failures to escalate deterioration. Concerns also related to out-of-hours and weekend care and the patient-safety impact of split-site hospital arrangements.

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 and incomplete fluid balance charts
Wider context from the report
“3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular: - Poor communication by/between clinicians and nurses - Poor record keeping – medical and nursing - Poor leadership/supervision of nurses - Ward/Matron level - Inadequate supervision by on-call consultants of junior colleagues - Incorrectly calculated early warning scores - Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified - Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording) - The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores - Failure to repeat tests such as bloods and to act upon the results accordingly - Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent - Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics) ”
Source location
Mrs Kathleen Cooper · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Nov2016
Mid Kent and Medway
Concerns raised1
1. Incomplete fluid balance records
This report raised 5 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

Dennis Plater · 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

Dennis Plater died of natural causes at Medway Maritime Hospital on 3 February 2016, following deterioration associated with acute kidney injury, sepsis and metastatic lung adenocarcinoma. The report identified incomplete fluid-balance records, failures in NEWS scoring and escalation by an agency nurse, and concerns about the Trust’s monitoring of agency staff training and compliance.

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
Incomplete fluid balance records
Wider context from the report
“1) There were incomplete records kept and especially in respect of the fluid balance chart thereby rendering it an ineffective diagnostic tool. ”
Source location
Dennis Plater · Prevention of Future Deaths report
Page 3 · concerns
Open source report
11 Oct2016
Blackpool and the Fylde
Concerns raised1
1. Failure to provide food and maintain adequate fluid-balance records
This report raised 9 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

Barry THOMPSON · 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

Barry Thompson, an insulin-dependent diabetic, died on 27 February 2016 while a patient on the Acute Medical Unit, after being admitted with sepsis from diabetic foot ulcers and hyperglycaemia. The report identified concerns about failure to provide insulin, fluids, adequate monitoring, antibiotics and medical review, as well as inaccurate and incomplete records and ineffective information sharing during transfer between departments.

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 provide food and maintain adequate fluid-balance records
Wider context from the report
“(3) Monitoring patients’ basic needs. There was difficulty encountered giving Mr Thompson saline by way of a drip. He was given an infusion of 1 litre over 4 hours at 17.30. At 23.00 it was found that the original cannula had become detached but the remaining fluid in the sac was 700mls. Mr Thompson’s bed was wet with saline fluid. He did not therefore receive the intended dose. He was not given a further injection of antibiotics 6 hours after the first nor was he written up for it. He was not given insulin. He does not appear to have been given any food whilst a patient or adequate fluid balance charts maintained. He was not seen by a doctor on the AMU. He was on a range of medication on admission to hospital for co-morbidities. The importance of this or otherwise was not assessed by staff. ”
Source location
Barry THOMPSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
1 Jun2016
Surrey
Concerns raised1
1. Failure to accurately record routine observations, fluid balance and gastrointestinal losses
This report raised 6 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 5
1. Action
  Run an awareness campaign emphasising accurate fluid-balance documentation on Joan Booker Ward.
  Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated completed
2. Action
  Introduce training and competency assessments for staff completing fluid-balance charts.
  Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated completed
3. Action
  Develop a redesigned fluid-balance chart to support complete recording of patient input and output.
  Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated completed
1. Action
  Conduct a repeat in-depth audit of fluid-balance documentation after the new chart is introduced and embedded.
  Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated planned
2. Action
  Introduce the Vitalpac electronic system for capturing patient observations across most inpatient areas.
  Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated completed
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
9 Feb2016
Leicester City and South Leicestershire
Concerns raised1
1. Failure to complete fluid balance charts consistently and accurately
This report raised 4 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 2
1. Action
  Review the fluid balance chart and its relationship to the Trust Nutrition and Hydration Policy.
  Stated by Leicestershire Partnership NHS TrustStated planned
2. Action
  Implement the reviewed fluid-balance documentation approach and support it with training for all clinical staff.
  Stated by Leicestershire Partnership NHS TrustStated planned
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
14 Sep2015
Stoke-on-Trent and North Staffordshire
Concerns raised1
1. Inadequate recording of food and fluid intake
This report raised 15 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
  Share investigation learning with New Park House and recommend improvements to recording practices.
  Stated by Stoke-on-Trent City CouncilStated completed
Respondent positions 1
1. Position
  The investigation found no evidence that fluid and food records were difficult to interpret or inaccurately recorded.
  Stated by Stoke-on-Trent City CouncilDisputes the concern
AI-generated summary

Janine Eugenie Pierrette KAISER · 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

Janine Eugenie Pierrette KAISER died at a nursing home on 21 October 2014 from lobar pneumonia, with suppurative cystitis, a sacral pressure ulcer, aortic stenosis, multiple myeloma and stroke also recorded. The principal concerns included missed turns, inaccurate or falsified records, inadequate pressure-mattress checks, poor recording of food and fluid intake, inadequate staff training and continuity, delayed referral to tissue viability nurses, and insufficient response to weight loss and safeguarding concerns. The inquest concluded that she died from significant natural disease, with a contributing sacral ulcer whose progress had been compromised by gaps in nursing care.

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
Inadequate recording of food and fluid intake
Wider context from the report
“2. Records were difficult to interpret and did not accurately record times at which fluid and food had been offered to the deceased. The amounts taken by the deceased were not adequately recorded. ”
Source location
Janine Eugenie Pierrette KAISER · 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
Share investigation learning with New Park House and recommend improvements to recording practices.

Verbatim wording from the response
“Some turns had been missed but Mrs Kaiser was known to regularly refuse to comply with the turn regime in place. It was acknowledged that such refusals were not always documented and the home took this away as a recommendation from the investigation for further work with the staff.”

Source location
2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
Page 3 · response
Published 14 July 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
The investigation found no evidence that fluid and food records were difficult to interpret or inaccurately recorded.

Verbatim wording from the response
“2. Records were difficult to interpret and did not accurately record times at which fluid and food had been offered to the deceased. The amounts taken by the deceased were not adequately recorded”

Source location
2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
Page 3 · response
Published 14 July 2015
Open published response
24 Jun2015
Brighton and Hove
Concerns raised1
1. Failure to document and adhere to fluid restrictions
This report raised 18 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 2
1. Action
  Introduce integrated documentation for all clinical staff treating patients on Twineham ward.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
2. Action
  Develop and deliver a Twineham ward training package on accurate documentation and the consequences of poor documentation.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
AI-generated summary

MR. ANTHONY GEERTS · 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

Mr. Anthony Geerts sustained a fractured neck of femur, underwent surgery and was transferred for rehabilitation before being moved to a nursing home. He later returned to hospital with hospital-acquired pneumonia and a possible urinary tract infection, and died on 21 November 2014. The concerns included inadequate rehabilitation, incomplete records and monitoring, poor communication and discharge planning, and failures in managing his continence, fluid restriction and possible chest infection; the inquest concluded that neglect at Princess Royal Hospital contributed to his death.

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 document and adhere to fluid restrictions
Wider context from the report
“Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly. In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for. His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as (a) There was insufficient physiotherapy staff to do so and (b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th. Neither Mr. GEERTS nor his family were involved in this decision. Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th. Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio. For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection. No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st. Specifically at Princess Royal Hospital: • Notes not completed. • No nursing notes and no NEWS for 10th or 11th • Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded. • No plan for physiotherapy • No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented. • No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented. • No referral of lack of urinary continence. Therefore no plan regarding this. • Failed Trial without catheter on 3rd November 2014. • Bowel monitoring chart not complete • Discharge planning non-existent or inadequate • Communication with patient and family virtually non-existent • No senior review from 4th November 2014; possibility of chest infection not followed up. • Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction. • Discharge lounge information incorrect. ”
Source location
MR. ANTHONY GEERTS · 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
Introduce integrated documentation for all clinical staff treating patients on Twineham ward.

Verbatim wording from the response
“b) introduction of integrated documentation for use by all the clinical staff treating each patient on the ward”

Source location
2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 24 June 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
Develop and deliver a Twineham ward training package on accurate documentation and the consequences of poor documentation.

Verbatim wording from the response
“c) joint development of a training package for all the staff based on Twineham ward, by the senior physiotherapy and nursing staff, to assist with accurate and detailed documentation. This includes a specific focus on the potential consequences of poor documentation”

Source location
2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 24 June 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to accurately record fluid intake and output

Concerns raised1

Failure to complete the fluid balance chart

Concerns raised1

Failure to keep patient records relating to urine charts

Concerns raised1

Inaccurate and incomplete fluid balance charts

Concerns raised1

Incomplete fluid balance records

Concerns raised1

Failure to provide food and maintain adequate fluid-balance records

Concerns raised1

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

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.5

Concerns raised1

Failure to complete fluid balance charts consistently and accurately

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.2

Concerns raised1

Inadequate recording of food and fluid intake

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 document and adhere to fluid restrictions

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.2

Actions described in response 5

Actions described in response 2

Actions described in response 1

Respondent positions 1

Actions described in response 2