Brunswick Ward at Lindridge

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First report 14 Feb 2017•Latest report 14 Feb 2017

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

Statements from Brunswick Ward at Lindridge linked to the concerns in each report. Select any concern, action or position to view the source wording.

14 Feb2017
Brighton and Hove
Concerns raised26
1. Delays in referring patients to required specialist services
2. Delays in review by a Parkinson’s nurse specialist
3. Failure to assist patients with mobilising
1. Failure to carry out prescribed saline eye cleaning
2. Failure to record dates of specialist referrals
3. Delays in administering required enemas
4. Failure to make mobility central to the care plan
5. Failure to complete requested patient re-weighing
6. Failure to refer nutritionally deteriorating patients to dieticians
7. Failure to adequately address the core medication regimen
8. Failure to recognise deterioration in mobility
9. Failure to hand over medical instructions and recommendations
10. Failure to record reasons for medication changes
11. Failure to incorporate family information into falls risk assessment
12. Failure to properly assess mental capacity
13. Delays in completing Waterloo pressure-risk scoring
14. Lack of a coherent, considered and reviewed care plan
15. Delays in completing thromboprophylaxis assessment
16. Failure to maintain a timely bowel chart
17. Failure to discuss medication changes
18. Failure to review nutritional risk after reduced eating
19. Failure to ensure timely provision and use of pressure-relieving equipment
20. Failure to appoint a care coordinator under the Care Programme Approach
21. Failure to regularly review original assessments
22. Incomplete mental-capacity documentation at discharge
23. Failure to respond to substantial weight loss
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised26

Delays in referring patients to required specialist services

Delays in review by a Parkinson’s nurse specialist

Failure to assist patients with mobilising

Failure to carry out prescribed saline eye cleaning

Failure to record dates of specialist referrals

Delays in administering required enemas

Failure to make mobility central to the care plan

Failure to complete requested patient re-weighing

Failure to refer nutritionally deteriorating patients to dieticians

Failure to adequately address the core medication regimen

Failure to recognise deterioration in mobility

Failure to hand over medical instructions and recommendations

Failure to record reasons for medication changes

Failure to incorporate family information into falls risk assessment

Failure to properly assess mental capacity

Delays in completing Waterloo pressure-risk scoring

Lack of a coherent, considered and reviewed care plan

Delays in completing thromboprophylaxis assessment

Failure to maintain a timely bowel chart

Failure to discuss medication changes

Failure to review nutritional risk after reduced eating

Failure to ensure timely provision and use of pressure-relieving equipment

Failure to appoint a care coordinator under the Care Programme Approach

Failure to regularly review original assessments

Incomplete mental-capacity documentation at discharge

Failure to respond to substantial weight loss