14 Feb 2017 Derek LEE · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 26 Delays in referring patients to required specialist services View source Delays in review by a Parkinson’s nurse specialist View source Failure to assist patients with mobilising View source Failure to carry out prescribed saline eye cleaning View source Failure to record dates of specialist referrals View source Delays in administering required enemas View source Failure to make mobility central to the care plan View source Failure to complete requested patient re-weighing View source Failure to refer nutritionally deteriorating patients to dieticians View source Failure to adequately address the core medication regimen View source Failure to recognise deterioration in mobility View source Failure to hand over medical instructions and recommendations View source Failure to record reasons for medication changes View source Failure to incorporate family information into falls risk assessment View source Failure to properly assess mental capacity View source Delays in completing Waterloo pressure-risk scoring View source Lack of a coherent, considered and reviewed care plan View source Delays in completing thromboprophylaxis assessment View source Failure to maintain a timely bowel chart View source Failure to discuss medication changes View source Failure to review nutritional risk after reduced eating View source Failure to ensure timely provision and use of pressure-relieving equipment View source Failure to appoint a care coordinator under the Care Programme Approach View source Failure to regularly review original assessments View source Incomplete mental-capacity documentation at discharge View source Failure to respond to substantial weight loss View source See 23 more concerns
Responses linked to these concerns
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Delays in referring patients to required specialist services
Wider context from the report “(9) There was no evidence of dates when Mr Lee was referred to the Occupational Therapist, the Physiotherapist, the dieticians or the Parkinson’s Specialist Nurse. At the Inquest I heard evidence that these referrals should have taken place as soon as possible after admission and certainly within the first three or four days . It is clear from the evidence that very little happened so far as Mr Lee was concerned until the 9th May. Too late.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Delays in review by a Parkinson’s nurse specialist
Wider context from the report “(11) It was not until the 12th May – two weeks after Mr Lee’s admission to Brunswick Ward – that he was seen by the Parkinson’s Nurse Specialist. When the Specialist Nurse saw Mr Lee he made three important recommendations and asked for feedback within seven days – the referral to the Speech and Language Therapy Team was done the next day.
The enema did not take place for two days. Too long and possibly dangerous.
The change in medication was never even discussed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Failure to assist patients with mobilising
Wider context from the report “(10) There was apparently no appreciation of the deterioration in Mr Lee’s mobility. He was at high risk of falls and yet the mobilisation of a Parkinson’s patient is imperative and also since he was being specialised during his entire admission there is absolutely no excuse for not trying to assist him with mobilising .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out prescribed saline eye cleaning
Wider context from the report “(7) Medical instructions and recommendations were not handed over. One example relates to instructions to clean Mr Lee’s infected eyes with saline every two hours to keep them open. This was not done and when he arrived at the Acute Hospital his eyes were crusted shut.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Failure to record dates of specialist referrals
Wider context from the report “(9) There was no evidence of dates when Mr Lee was referred to the Occupational Therapist, the Physiotherapist, the dieticians or the Parkinson’s Specialist Nurse. At the Inquest I heard evidence that these referrals should have taken place as soon as possible after admission and certainly within the first three or four days. It is clear from the evidence that very little happened so far as Mr Lee was concerned until the 9th May. Too late.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Delays in administering required enemas
Wider context from the report “(11) It was not until the 12th May – two weeks after Mr Lee’s admission to Brunswick Ward – that he was seen by the Parkinson’s Nurse Specialist. When the Specialist Nurse saw Mr Lee he made three important recommendations and asked for feedback within seven days – the referral to the Speech and Language Therapy Team was done the next day.
The enema did not take place for two days. Too long and possibly dangerous.
The change in medication was never even discussed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Failure to make mobility central to the care plan
Wider context from the report “(3) His Falls Risk Assessment was flawed in that it failed to take into account information from his wife and son as to how he was mobilising at home. Mobilisation in Mr Lee’s case should have been at the core of the Care Plan because he was suffering from Parkinson’s Disease, where if possible, it is important to maintain mobility. Brunswick Ward should know that.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Failure to refer nutritionally deteriorating patients to dieticians
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately address the core medication regimen
Wider context from the report “(1) Mr Lee’s medication regimen which was to be the core of the admission was barely addressed and no reasons for any changes in medication appear in his notes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise deterioration in mobility
Wider context from the report “(10) There was apparently no appreciation of the deterioration in Mr Lee’s mobility. He was at high risk of falls and yet the mobilisation of a Parkinson’s patient is imperative and also since he was being specialised during his entire admission there is absolutely no excuse for not trying to assist him with mobilising.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Failure to hand over medical instructions and recommendations
Wider context from the report “(7) Medical instructions and recommendations were not handed over. One example relates to instructions to clean Mr Lee’s infected eyes with saline every two hours to keep them open. This was not done and when he arrived at the Acute Hospital his eyes were crusted shut.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Failure to record reasons for medication changes
Wider context from the report “(1) Mr Lee’s medication regimen which was to be the core of the admission was barely addressed and no reasons for any changes in medication appear in his notes .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate family information into falls risk assessment
Wider context from the report “(3) His Falls Risk Assessment was flawed in that it failed to take into account information from his wife and son as to how he was mobilising at home . Mobilisation in Mr Lee’s case should have been at the core of the Care Plan because he was suffering from Parkinson’s Disease, where if possible, it is important to maintain mobility. Brunswick Ward should know that.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Failure to properly assess mental capacity
Wider context from the report “(2) Re: Admission Documentation – Mental capacity was not properly assessed and when Mr Lee was discharged from the ward after three weeks on the 17th May the paperwork in that respect was still incomplete.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Delays in completing Waterloo pressure-risk scoring
Wider context from the report “(4) No Waterloo score was done until the 4th May. Too late. No appropriate pressure relieving equipment was ordered until the 12th May. There was no evidence before me that the equipment was ever received or used for Mr Lee. When Mr Lee was admitted to the Acute Hospital he had a Grade 2 pressure sore on his Sacrum.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Lack of a coherent, considered and reviewed care plan
Wider context from the report “(13) There was no coherent and carefully considered and reviewed Care Plan.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Delays in completing thromboprophylaxis assessment
Wider context from the report “(5) The thromboprophylaxis assessment which should have been carried out on either the 27th or 28th April was not done until the 6th May .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a timely bowel chart
Wider context from the report “(6) No bowel chart was kept until the 12th May. Why Why not? Even non nursing, non-medical professionals know that one of the several dangers of Parkinson’s Disease is constipation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss medication changes
Wider context from the report “(11) It was not until the 12th May – two weeks after Mr Lee’s admission to Brunswick Ward – that he was seen by the Parkinson’s Nurse Specialist. When the Specialist Nurse saw Mr Lee he made three important recommendations and asked for feedback within seven days – the referral to the Speech and Language Therapy Team was done the next day.
The enema did not take place for two days. Too long and possibly dangerous.
The change in medication was never even discussed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Failure to review nutritional risk after reduced eating
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely provision and use of pressure-relieving equipment
Wider context from the report “(4) No Waterloo score was done until the 4th May. Too late. No appropriate pressure relieving equipment was ordered until the 12th May. There was no evidence before me that the equipment was ever received or used for Mr Lee. When Mr Lee was admitted to the Acute Hospital he had a Grade 2 pressure sore on his Sacrum.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Failure to appoint a care coordinator under the Care Programme Approach
Wider context from the report “(14) A Care Co-ordinator was not appointed , even though at the Inquest, it was confirmed that Mr Lee was being looked after on the Care Programme Approach (CPA).
The appointment of a Care Co-ordinator is at the heart of this framework and it was clear that such an appointment could have been helpful if not crucial in Mr Lee’s case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Failure to regularly review original assessments
Wider context from the report “(12) As time went on there was no regular review of his original Assessments . This should have been done apparently by his Primary Nurse who carried out none of these functions and therefore her appointment for Mr Lee was irrelevant.
There should be a review of the role of Primary Nurse.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Incomplete mental-capacity documentation at discharge
Wider context from the report “(2) Re: Admission Documentation – Mental capacity was not properly assessed and when Mr Lee was discharged from the ward after three weeks on the 17th May the paperwork in that respect was still incomplete .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brunswick Ward at Lindridge; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to substantial weight loss
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.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations