11 Aug 2022 Ms Katie Horne · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Delays in gastroenterology consultation on care View source Delays in review and follow-up of crucial blood test results View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Ms Katie Horne · 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
Ms Katie Horne presented with jaundice, developed severe hepatitis and liver failure, tested positive for Covid-19, developed Covid pneumonitis, and died on 11 April 2020. The principal concerns were delays in identifying crucial blood test results, consulting a gastroenterologist, starting steroid therapy, and referring her for possible liver transplantation.
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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Delays in gastroenterology consultation on care
Wider context from the report “Despite multiple attendances as an outpatient with deteriorating hepatitis, it took 15 days for crucial blood test results to be seen by the doctors (in part due to lab backlog but there was no evidence of any doctor prioritising or chasing the results) or for a gastroenterologist to be consulted on care . This led to a liver biopsy not being possible (in part as her blood clotting had deteriorated) and later than necessary commencement of steroid therapy and consequent later referral for liver transplantation at Kings College Hospital.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Delays in review and follow-up of crucial blood test results
Wider context from the report “Despite multiple attendances as an outpatient with deteriorating hepatitis, it took 15 days for crucial blood test results to be seen by the doctors (in part due to lab backlog but there was no evidence of any doctor prioritising or chasing the results ) or for a gastroenterologist to be consulted on care. This led to a liver biopsy not being possible (in part as her blood clotting had deteriorated) and later than necessary commencement of steroid therapy and consequent later referral for liver transplantation at Kings College Hospital.
” Open source report
24 Jun 2015 MR. ANTHONY GEERTS · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 19 Failure to involve patients and families in discharge decisions View source Failure to complete clinical notes View source Failure to communicate adequately with patients and families View source Failure to complete requested blood tests View source Inadequate discharge planning View source Failure to provide rehabilitation on a rehabilitation ward View source Failure to provide accurate discharge lounge information View source Failure to manage trials without catheter safely View source Failure to follow and document ward transfer procedures View source Failure to communicate patients' care needs during ward transfers View source Failure to refer and plan for urinary incontinence View source Failure to address patients' mental health needs and anxieties View source Failure to document rehabilitation exercise View source Failure to complete bowel monitoring charts View source Failure to provide senior review and follow up suspected infection View source Insufficient physiotherapy staffing for rehabilitation patients View source Failure to document and adhere to fluid restrictions View source Failure to record nursing observations and NEWS View source Failure to maintain a physiotherapy plan View source See 16 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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. The report was sent to Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to involve patients and families in discharge decisions
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.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to complete clinical notes
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.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate adequately with patients and families
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.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to complete requested blood tests
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.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Inadequate discharge planning
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.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to provide rehabilitation on a rehabilitation ward
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.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate discharge lounge information
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 .
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to manage trials without catheter safely
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.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to follow and document ward transfer procedures
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.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate patients' care needs during ward transfers
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.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to refer and plan for urinary incontinence
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.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to address patients' mental health needs and anxieties
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.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to document rehabilitation exercise
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.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to complete bowel monitoring charts
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.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to provide senior review and follow up suspected infection
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.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Insufficient physiotherapy staffing for rehabilitation patients
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.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
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.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to record nursing observations and NEWS
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.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a physiotherapy plan
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.
” Open source report
3 Apr 2014 Graham Harold WATTS · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 4 Failure to communicate discharge information to receiving care providers and family View source Failure to ensure patients are medically fit for discharge View source Failure to complete discharge paperwork View source Failure to maintain an ongoing discharge process View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Graham Harold WATTS · 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
Graham Harold Watts was discharged from Princess Royal Hospital to his nursing home, where he arrived hypothermic, hypotensive, oedematous and sleepy. The report raised concerns about a flawed discharge process, blank paperwork and a lack of communication with the nursing home and his son. It also recorded evidence that, had he not fractured his hip in a fall, he would not have died when he did.
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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate discharge information to receiving care providers and family
Wider context from the report “(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge.
(2) The discharge paperwork was effectively blank.
(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy.
(4) It is acknowledged and accepted that a change of environment increases the risks of fall.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure patients are medically fit for discharge
Wider context from the report “(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge.
(2) The discharge paperwork was effectively blank.
(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy.
(4) It is acknowledged and accepted that a change of environment increases the risks of fall.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to complete discharge paperwork
Wider context from the report “(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge.
(2) The discharge paperwork was effectively blank.
(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy.
(4) It is acknowledged and accepted that a change of environment increases the risks of fall.
” 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 Princess Royal Hospital, Haywards Heath; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an ongoing discharge process
Wider context from the report “(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge.
(2) The discharge paperwork was effectively blank.
(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy.
(4) It is acknowledged and accepted that a change of environment increases the risks of fall.
” 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