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

Distinct published reports

Individual concerns
15

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
13

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

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.

  1. Northumberland

    AI-generated summary

    REDACTED Deceased · 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

    The deceased was a 17-year-old girl with autism, anxiety, significant weight loss and extreme malnutrition who died in hospital on 5 May 2024 after cardiac output was lost following vomiting during preparation for insertion of a central venous line. The principal concerns included inadequate monitoring of her weight, lack of face-to-face assessments, failure to refer or escalate care appropriately, discharge from CAMHS without direct assessment, poor communication and unclear oversight of outpatient 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

    Lack of physical face-to-face monitoring of weight

    Wider context from the report

    “1.The deceased’s weight was not adequately monitored from November 2023. I am concerned there was no physical or face to face monitoring of the deceased’s weight from November 2023. I heard about the importance of physical eye to eye contact and examination on a face-to-face basis so that one can see evidence of the skin, properly see the patient’s face and when doing the height and weight asking for the removal some of their clothing to assess muscle mass. ”

    Source location

    REDACTED Deceased · Prevention of Future Deaths report
    Page 3 · 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

    Reinforce face-to-face contact requirements for patients with weight loss or malnutrition through team reminders and monthly meetings.

    Verbatim wording from the response

    “• Enhanced Face-to-Face Contact: The GP surgery already runs a primarily face-to-face appointment system, but we have reminded the team of the importance of this means of access, particularly where weight loss or malnutrition is a concern, to ensure accurate physical assessments. We will continue to reiterate the importance of face to face contacts at our monthly meetings and when any changes to appointment ledgers are considered.”

    Source location

    2025-0314 - Response from 49 Marine Avenue Surgery
    Page 2 · response
    Published 14 July 2025

    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

    Routinely offer face-to-face Dietetics appointments as first contact for patients referred for nutritional support or weight loss, with in-person follow-up after necessary telephone assessment.

    Verbatim wording from the response

    “9. From August 2025, face to face appointments are now routinely offered by the Dietetics service as first contact for any patient referred for nutritional support and weight loss (irrespective of the cause). If telephone contact is required for timeliness, then an in-person review appointment will then be offered after the initial telephone assessment.”

    Source location

    2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
    Page 3 · response
    Published 14 July 2025

    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

    Cascade safety messages on accurate height and weight measurement, assessment frequency and documentation through Trust communications and policy.

    Verbatim wording from the response

    “11. Internal communications and safety messages have been cascaded to Trust staff regarding the importance of obtaining accurate height and weight measurements in July 2025, including frequency of assessment and clarity on how the measurements were obtained, documented within the approved Trust-wide Nutrition and Hydration Policy.”

    Source location

    2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
    Page 3 · response
    Published 14 July 2025

    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

    Offer home visits to higher-risk patients who cannot or will not attend an in-person Trust appointment.

    Verbatim wording from the response

    “29. The standard referral criteria to the Dietetics service for nutrition support is patients with a BMI of less than 18.5 and/or 5-10% weight loss within 3-6 months. Higher risk patients (i.e. those referred with a BMI of less than 17.5, in line with MEED definitions for immediate risk to life) can now be offered a home visit, if it is felt that the patient won't or can't attend an in-person appointment at one of the Trust sites.”

    Source location

    2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
    Page 6 · response
    Published 14 July 2025

    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

    Offer face-to-face appointments to all higher-risk patients, using telephone contact only when needed for timely intervention and followed by in-person review.

    Verbatim wording from the response

    “30. All higher risk patients will be offered a face-to-face appointment going forward and if a telephone contact is required to facilitate a timely intervention it will be followed by an in-person appointment to ensure accurate weight and height is recorded. Face-to-face appointments for all patients who are not triaged as ‘higher risk’ are offered where possible and would be based on individual clinical need and may require further commissioning discussions.”

    Source location

    2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
    Page 6 · response
    Published 14 July 2025

    Open published response

  2. Manchester South

    AI-generated summary

    Esme Vera Louise Atkinson · 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

    Esme Vera Louise Atkinson was born on 7 February 2024 and died at Stepping Hill Hospital on 17 March 2024 after suddenly stopping breathing. A post-mortem examination found a ventricular septal defect, and the report states that earlier identification would probably have prevented her death at that time. Concerns included missed opportunities to identify the defect, inadequate recognition of feeding and weight concerns, gaps in professional training and information sharing, and the absence of routine echocardiography and auditing of cardiac images in relevant circumstances.

    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 track infant weight centiles in the early stages

    Wider context from the report

    “7. The evidence of the paediatricians at the inquest was that tracking weight on the centile chart even from an early point assisted in understanding if there was a significant issue in relation to feeding triggering professional curiosity. However the evidence from the Health Visitor appeared to suggest that centile tracking was not seen as useful before 1 month and the red book was not used to look at weight centile tracking in the early stages. ”

    Source location

    Esme Vera Louise Atkinson · 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

    Digitalise the red book and progressively add information and functionality to improve access to growth and feeding data.

    Verbatim wording from the response

    “Once feeding is established, babies should usually be weighed at around 8, 12 and 16 weeks and 1 year at the time of routine immunisations. We recognise that the red book is an important tool for tracking and sharing information between healthcare professionals, and we are digitalising the red book to improve access to this data. Over time, we will add more information and create more functionality, including AI analytics, to ensure the best care is provided for the child, including detecting any anomalies in weight gain or feeding.”

    Source location

    Response from Department of Health and Social Care
    Page 4 · response
    Published 18 June 2025

    Open published response

  3. Bedfordshire and Luton

    AI-generated summary

    Jacqueline GREEN · 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

    Jacqueline GREEN was admitted to Bedford Hospital after a fall and was found to be very weak, frail, cachectic and dehydrated. She received paracetamol at a dose intended for patients weighing over 50 kg despite weighing 33.6 kg, subsequently developed paracetamol-induced liver injury and died from liver failure. The concerns included inadequate safeguards for prescribing paracetamol to low-weight adults, unexplained variation in the administration of doses, and incomplete implementation of relevant safety measures.

    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 ensure accurate patient weights are entered before paracetamol prescribing

    Wider context from the report

    “3. Despite the PSII report referencing the 2022 HSSIB report and recommending that this should be shared with staff, relevant Safety Observations made in the HSSIB Report appear to have been insufficiently addressed: (a) Although Bedford Hospitals NHS Trust are now using the Nevercentre electronic record system which, since 28th February 2024, has included the height and weight of patients and prevents a prescribing doctor from prescribing without a patient’s weight having first been entered, staff are still able to enter a estimated weight and there do not appear to be any alerts on this system to advise of the need for weight accuracy in the prescription of oral paracetamol and consideration of the risk of liver toxicity in those weighing under 50 kg (as advised in Safety Observation 02/2022/151); (b) Whilst the PSII report states as an Action that “Patients should be weighed on admission and the information documented”, other than the provision of a ‘pat slide’, no other practical actions are planned for actually achieving this outcome, particularly in respect of those adults at risk of an unintentional paracetamol overdose, such as an alert aimed at those administering medication as well as those prescribing it (as advised in Safety Observation 02/2022/151). ”

    Source location

    Jacqueline GREEN · 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

    Add EPMA prescribing prompts requiring accurate weight recording and appropriate paracetamol dosing, including liver-toxicity warnings below 50 kilograms.

    Verbatim wording from the response

    “There is now a prompt when prescribing paracetamol (all routes) on EPMA that reminds prescribers of the need to ensure there is an accurate weight recorded and that the dose is appropriate.”

    Source location

    Response from Bedford Hospitals NHS Foundation Trust
    Page 3 · response
    Published 11 April 2025

    Open published response

  4. 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

    Failure to weigh patients to support oedema management

    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

  5. 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

    Reliance on outdated weight measurements in multidisciplinary reviews

    Wider context from the report

    “7. Multi-Disciplinary Team (MDT) Meetings were not held every 4 to 6 weeks as required. At MDT meetings which did take place, out of date weight measurements were recorded and relied upon for Ben. His increasing weight gain was not discussed at these meetings and weight loss was not set as a desirable or essential goal ”

    Source location

    Ben Buster KING · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Inner South London

    AI-generated summary

    Mr Adrian Ashford · 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 Adrian Ashford died in Queen Elizabeth Hospital on 15 December 2018 after a massive upper gastrointestinal bleed, with the medical cause of death recorded as upper gastrointestinal bleeding due to chronic peptic ulcer. Concerns included the absence of a systematic process for recording weights and failures to identify or respond to risks of gastrointestinal bleeding, including consideration of gastroenterology referral.

    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 a systematic process for recording weights

    Wider context from the report

    “1. ████████ GP and ████████ Divisional Medical Director, both gave evidence of the value of having some system for regular weighing, and that it might save lives. This would enable reported weight loss to be verified and quantified and highlight triggers for investigation in a timely manner. But there appears to be no systematic process of recording weights. ”

    Source location

    Mr Adrian Ashford · 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

    Implement a trust-wide electronic patient record enabling staff to record and view patient weights electronically.

    Verbatim wording from the response

    “- The Trust has now implemented a trust-wide electronic patient record system (since May-June 2019). The system enables weight to be consistently recorded electronically which can then be observed by all staff within the Trust”

    Source location

    2020-0054-Response-from-Lewisham-and-Greenwich-NHS-Trust.-Redacted
    Page 2 · response
    Published 18 March 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

    Operate a systematic weekly weight assessment process after admission, with weights and heights visible to Trust staff.

    Verbatim wording from the response

    “- The Trust also has a systematic process in place that covers weekly weights. On admission, there is a nursing task called safety assessment. The safety assessment is a set of assessments bundled into one task. One of the assessments within the safety assessment is the Nutritional Assessment, which includes patient weight/ height/ BMI. This task is then presented automatically on a weekly basis following admission. Weights and heights are then viewable in iView for all staff within the Trust”

    Source location

    2020-0054-Response-from-Lewisham-and-Greenwich-NHS-Trust.-Redacted
    Page 2 · response
    Published 18 March 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

    Provide an electronic medicines-management order for recording patient weights at a specified frequency.

    Verbatim wording from the response

    “- Additionally, the electronic medicines management system has recently implemented a new way in which to get weights onto the system. There is now an order on the system that can be ordered to any desired frequency. This needs to be completed from the drug chart. Once completed in the drug chart the weights are viewable in iView as well.”

    Source location

    2020-0054-Response-from-Lewisham-and-Greenwich-NHS-Trust.-Redacted
    Page 2 · response
    Published 18 March 2020

    Open published response

  7. Portsmouth and South East Hampshire

    AI-generated summary

    Scott Douglas Hooper · 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

    Scott Douglas Hooper, aged 46, died on 22 March 2016 after sustaining complex pelvic fractures in an unwitnessed workplace forklift accident and later suffering a pulmonary embolism and deep vein thrombosis. The principal concerns were that his weight was incorrectly recorded, affecting the prescribed anticoagulant dose, and that a decision to withhold a dose was not recorded with the decision-maker identified.

    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 or obtain patient weight for weight-dependent anticoagulant dosing

    Wider context from the report

    “1. On admission to SGH on 12 March, Mr Hooper's weight was incorrectly recorded as 80kg when the reality was his true weight was 107 kg – a difference of 27 kg (or 3.5lbs) which is a considerable difference. This is important as the amount of anti-coagulant drugs to be given according to the SGH thromboprophylaxis protocol is calculated on weight. 2. As stated above, on 15 March when the clinical decision was made to withhold the morning dose of Tpx medication it could not be ascertained who made the decision. This was a significant clinical decision and it is a basic requirement that all clinical decisions are recorded in order to capture capturing who made the decision and why. In respect of both of these concerns, during the investigation I learned through the Root Cause Analysis that a Trauma & Orthopaedic Morbidity & Mortality meeting had been held. In addition, I was told during the inquest that a nonogram was now in use to improve weight estimation for those patients where it was not possible to obtain actual weight and that training was underway in relation to its use for elderly patients. I also heard that some new beds with built in weight indicating scales were to be purchased within 2 months subject to cost and commissioning. Whilst a valuable tool, a single T&O M&M meeting is only effective for those doctors and nursing staff who attend. I was not given any other detail as to how the valuable lessons to be learned from this case were to be spread to clinical staff across the T&O department or the whole Trust as weight estimation can be equally important in many other medical specialisms. I was told during the inquest that training was currently taking place in respect of elderly patients but I was not given a plan or timetable for other high risk patients such as Mr Hooper who was only 46 years old and suffered from an acute crush pelvic trauma which had the potential to be life threatening. Mr Hooper died on 22 March 2016 but as yet no active steps have been taken to address patients who fall into the same category. The same principle can be said to apply to bed purchase and it did not appear to be an agreed action that beds with scales would be used to improve the problem of weight estimation in order to ensure accurate dosage of essential medication. ”

    Source location

    Scott Douglas Hooper · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  8. Brighton and Hove

    AI-generated summary

    Derek LEE · 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

    Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.

    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 requested patient re-weighing

    Wider context from the report

    “(8) The MUST score was properly calculated on admission but not reviewed when it was clear he was not eating. There was no evidence of any reaction to Mr Lee’s substantial weight loss. There was no referral to dieticians. They just happened to attend a multi-disciplinary meeting on the 9th May (he was admitted on the 27th April and by the 9th May had lost 10 and ¾ pounds – 4.80 kilos). Re-weighing was requested by the dieticians. It did not take place. ”

    Source location

    Derek LEE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Plymouth, Torbay and South Devon

    AI-generated summary

    Harry Glibbery · 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

    Harry Glibbery had a chronically infected left hip replacement and underwent a Girdlestone procedure before developing pulmonary emboli. He died on 7 April 2016 after a catastrophic intracerebral haemorrhage while receiving Clexane. The principal concerns were that the Clexane prescription exceeded the Derriford Protocol dose, the error was not identified during pharmacy reviews, and difficulties weighing him may have prevented a dose review as he lost weight.

    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

    Inability to weigh patients reliably

    Wider context from the report

    “(3) I was advised that during Mr Glibbery’s admission he lost a substantial amount of weight estimated at between 6 – 10 kilograms. ████████ (who gave evidence) expressed their difficulties in having patients weighed. This is particularly difficult for patients who have undergone hip replacements where, I was told, a hoist that is available is not high enough to return patients back to their beds. The importance of this is obvious in patients whose medication is weight-dependent. It is believed that Mr Glibbery was on the cusp of requiring a downward review of the amount of Clexane prescribed to him. ”

    Source location

    Harry Glibbery · 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

    Monitor postoperative patient weighing with Senior Nurses.

    Verbatim wording from the response

    “measurements being taken, even if there are considerable technical issues. We will monitor this with the Senior Nurses. This does represent significant challenges, both as a result of the patient’s condition and the various mechanisms which are common to patients in this particular.”

    Source location

    2016-0292-Response-by-Plymouth-Hospital-NHS-Trust
    Page 3 · response
    Published 16 August 2016

    Open published response

  10. Manchester South

    AI-generated summary

    Michael Guy Hutchence · 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 Guy Hutchence broke his lower leg after slipping on an icy pavement and died in hospital on 28 January 2016. The report raised concerns about repeated ward moves, staffing and record-keeping, weight-based anticoagulant dosing and inconsistent weight recording, inadequate equipment for leg elevation, and delays to surgery after two operation kits were found to be non-sterile. The stated medical cause of death included bronchopneumonia, deep vein thrombosis and pulmonary embolus, and fractured tibia and fibula.

    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 accurate patient weights consistently

    Wider context from the report

    “4. In addition to the above problem, the body weight was recorded on some occasions in metric and others in imperial weights. This can and does lead to confusion. On one page of the notes, the predicted weight was shown as 15stone 10lbs which was in fact the actual weight and NOT the predicted weight. For the purpose of the accurate delivery of many drugs including anti-coagulants, accurate weight recording is essential. ”

    Source location

    Michael Guy Hutchence · 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

    Continue an awareness drive requiring staff to record patient weight and height using metric measurements.

    Verbatim wording from the response

    “There is currently an ongoing awareness drive to ensure all staff are recording weight and height in the metric format.”

    Source location

    2016-0228-Response-by-Stockport-NHS-Trust
    Page 2 · response
    Published 20 June 2016

    Open published response
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Data last updated 7 September 2026