6 Jun 2023 Alexander Shone BLEWITT · Prevention of Future Deaths report Milton Keynes
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Concerns raised 7 Failure to correct and monitor prescribing clinicians' failure to sign off IV fluid prescriptions View source Lack of effective, reliable recording of intravenous fluids administered in the emergency department View source Failure to accurately transcribe communications received at emergency department triage View source Failure to bring issues of concern to the attention of hospital authorities View source Failure of attending doctors to review source communications themselves View source Failure of incident investigations to provide detailed, evidence-challenging analysis View source Failure of treating doctors to make accurate clinical notes of major presenting symptoms View source See 4 more concerns
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Alexander Shone BLEWITT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alexander Shone Blewitt died at Milton Keynes University Hospital on 11 July 2022 after returning to the emergency department with faecal incontinence and abdominal pain, following an earlier visit where he had been referred from an urgent care centre. A possible acute abdomen was confirmed by CT, and he suffered a cardiac arrest before surgery. Concerns included inaccurate communication of important symptoms and treatment information, inadequate clinical recording, and the absence of reliable records of intravenous fluids administered in the emergency department.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Bedfordshire, Luton and Milton Keynes Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to correct and monitor prescribing clinicians' failure to sign off IV fluid prescriptions
Wider context from the report “[5] The Incident Investigation Report which is in part designed to assist with learning from adverse events was of a generally poor standard. There was a failure to consider issues in detail; there was a failure to challenge the statements of clinicians where there were obvious contradictions between statements made and the medical record; there was a failure to put in place measures to correct and monitor prescribing clinicians failure to sign off on IV fluid prescriptions so that the contemporaneous record would be available for clinicians coming after them and they could see whether a patient had satisfactory or unsatisfactory fluid management . The only record in the case was a typed note by a junior doctor to the effect that it was thought Mr Blewitt had received 2 litres of fluid since arrival.
” 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 NHS Bedfordshire, Luton and Milton Keynes Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of effective, reliable recording of intravenous fluids administered in the emergency department
Wider context from the report “[1] At the time of Mr Blewitt's death there was no effective, reliable recording of intravenous fluids administered to patients in the emergency department . That in my view has potential to represent a threat to the safety and lives of patients suffering with a wide variety of different conditions. The author of the SI report who attended to give evidence did not, at the time of request 8 months later, was unable to demonstrate that the Trust had remedied that.
” 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 NHS Bedfordshire, Luton and Milton Keynes Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately transcribe communications received at emergency department triage
Wider context from the report “[3] On arrival at the ED a triage nurse summarised the communication from the urgent care centre. The triage nurse missed important points during the transcription . The attending doctor did not concern himself to look at the communication himself.
” 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 NHS Bedfordshire, Luton and Milton Keynes Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to bring issues of concern to the attention of hospital authorities
Wider context from the report “[2] Despite the 8 month interval between Mr Blewitt's death and the Inquest the issues of concern had not been brought to the attention of hospital authorities .
” 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 NHS Bedfordshire, Luton and Milton Keynes Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of attending doctors to review source communications themselves
Wider context from the report “[3] On arrival at the ED a triage nurse summarised the communication from the urgent care centre. The triage nurse missed important points during the transcription. The attending doctor did not concern himself to look at the communication himself .
” 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 NHS Bedfordshire, Luton and Milton Keynes Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of incident investigations to provide detailed, evidence-challenging analysis
Wider context from the report “[5] The Incident Investigation Report which is in part designed to assist with learning from adverse events was of a generally poor standard . There was a failure to consider issues in detail ; there was a failure to challenge the statements of clinicians where there were obvious contradictions between statements made and the medical record ; there was a failure to put in place measures to correct and monitor prescribing clinicians failure to sign off on IV fluid prescriptions so that the contemporaneous record would be available for clinicians coming after them and they could see whether a patient had satisfactory or unsatisfactory fluid management. The only record in the case was a typed note by a junior doctor to the effect that it was thought Mr Blewitt had received 2 litres of fluid since arrival.
” 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 NHS Bedfordshire, Luton and Milton Keynes Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of treating doctors to make accurate clinical notes of major presenting symptoms
Wider context from the report “[4] I was concerned that the treating doctor made aaneous note on the 9th July 2022 at Mr Blewitt's first presentation which failed to record the major presenting symptom, diarrhoea with faecal incontinence , which Mr Blewitt had communicated to the urgent care doctor who in turn had included that in her notes and letter to the ED. The treating doctor did record a flatly contradictory note to the effect there was no change in bowel habit .
” 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