20 Mar 2020 John Francis GREGORY · Prevention of Future Deaths report Inner North London
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Concerns raised 9 Failure to escalate and respond to prolonged inadequate fluid intake View source Failure to provide bedtime arrangements based on patients’ needs rather than nursing routine View source Failure to secure patients safely in wheelchairs View source Failure to provide adequate clothing for patients unable to dress themselves View source Failure to encourage patients to drink or eat when intake is inadequate View source Failure to provide consistent toileting and continence care View source Failure to consistently encourage sufficient drinking and eating View source Failure to monitor patients in communal areas View source Inaccurate recording of patients’ fluid intake View source See 6 more concerns
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AI-generated summary
John Francis GREGORY · 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
John Francis Gregory died after developing acute kidney injury associated with low oral fluid intake, in the context of Alzheimer’s disease and old age. Concerns included inadequate encouragement and monitoring of drinking in hospital rehabilitation and residential care, inaccurate fluid-intake records, and failures to escalate or respond to his deterioration at Muriel Street Resource Centre.
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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 University College Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate and respond to prolonged inadequate fluid intake
Wider context from the report “4. Mr Gregory’s oral fluid intake was also too low at Muriel Street, a nursing home specialising in the care of those with dementia.
On his last day at the home, Mr Gregory was described in the nursing notes as drinking, but his chart showed that he had drunk nothing since a cup of tea at 8.20am . The ambulance was called at 5.17pm.
The fact that he had not drunk the whole day was not escalated to a senior member of staff and there was no evidence that any steps had been taken to deal with this .
His fluid intake chart recorded him as repeatedly declining drinks, even at a time after he had lost consciousness and an ambulance had already been called for him.
This demonstrates that the chart was inaccurate. It raises the possibility that the chart was inaccurate in other ways. It raises the possibility that when Mr Gregory was described as declining drinks, in fact staff were not taking any steps to encourage him to drink, or to eat.
” 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 University College Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide bedtime arrangements based on patients’ needs rather than nursing routine
Wider context from the report “1. Whilst the sister in charge of Evergreen plainly led from the front and expected the highest standards, these were not always maintained by every member of staff.
On one occasion, a member of staff refused Mr Gregory’s family assistance to take him to the toilet; on more than one occasion his family found him in wet bedclothes; and he was put to bed at 7.30pm to fit in with nursing routine .
” 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 University College Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to secure patients safely in wheelchairs
Wider context from the report “3. On the day he was readmitted to hospital from Muriel Street, Mr Gregory’s family found him slumped unconscious in a public area of the home, a fact unnoticed by any member of staff.
He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests . He was cold and inadequately dressed, with his shirt undone and not wearing socks. By then Mr Gregory was not capable of dressing 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 University College Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate clothing for patients unable to dress themselves
Wider context from the report “3. On the day he was readmitted to hospital from Muriel Street, Mr Gregory’s family found him slumped unconscious in a public area of the home, a fact unnoticed by any member of staff.
He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests. He was cold and inadequately dressed, with his shirt undone and not wearing socks . By then Mr Gregory was not capable of dressing 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 University College Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to encourage patients to drink or eat when intake is inadequate
Wider context from the report “4. Mr Gregory’s oral fluid intake was also too low at Muriel Street, a nursing home specialising in the care of those with dementia.
On his last day at the home, Mr Gregory was described in the nursing notes as drinking, but his chart showed that he had drunk nothing since a cup of tea at 8.20am. The ambulance was called at 5.17pm.
The fact that he had not drunk the whole day was not escalated to a senior member of staff and there was no evidence that any steps had been taken to deal with this.
His fluid intake chart recorded him as repeatedly declining drinks, even at a time after he had lost consciousness and an ambulance had already been called for him.
This demonstrates that the chart was inaccurate. It raises the possibility that the chart was inaccurate in other ways. It raises the possibility that when Mr Gregory was described as declining drinks, in fact staff were not taking any steps to encourage him to drink, or to eat .
” 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 University College Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consistent toileting and continence care
Wider context from the report “1. Whilst the sister in charge of Evergreen plainly led from the front and expected the highest standards, these were not always maintained by every member of staff .
On one occasion, a member of staff refused Mr Gregory’s family assistance to take him to the toilet ; on more than one occasion his family found him in wet bedclothes ; and he was put to bed at 7.30pm to fit in with nursing routine.
” 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 University College Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently encourage sufficient drinking and eating
Wider context from the report “2. His oral fluid intake was considered by Evergreen Ward, and steps were taken to address this, but the intake recorded on his charts demonstrate that it remained too low .
Maintaining sufficient fluid intake was a challenge, but there is the possibility that not every member of staff encouraged him to drink and eat in the way the sister in charge did.
” 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 University College Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor patients in communal areas
Wider context from the report “3. On the day he was readmitted to hospital from Muriel Street, Mr Gregory’s family found him slumped unconscious in a public area of the home, a fact unnoticed by any member of staff .
He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests. He was cold and inadequately dressed, with his shirt undone and not wearing socks. By then Mr Gregory was not capable of dressing 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 University College Hospital; that does not assign responsibility.
PFD Monitor interpretation Inaccurate recording of patients’ fluid intake
Wider context from the report “4. Mr Gregory’s oral fluid intake was also too low at Muriel Street, a nursing home specialising in the care of those with dementia.
On his last day at the home, Mr Gregory was described in the nursing notes as drinking, but his chart showed that he had drunk nothing since a cup of tea at 8.20am. The ambulance was called at 5.17pm.
The fact that he had not drunk the whole day was not escalated to a senior member of staff and there was no evidence that any steps had been taken to deal with this.
His fluid intake chart recorded him as repeatedly declining drinks, even at a time after he had lost consciousness and an ambulance had already been called for him .
This demonstrates that the chart was inaccurate . It raises the possibility that the chart was inaccurate in other ways. It raises the possibility that when Mr Gregory was described as declining drinks, in fact staff were not taking any steps to encourage him to drink, or to eat.
” Open source report
30 Jul 2014 Monique Susanna WHITBREAD · Prevention of Future Deaths report Inner North London
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Concerns raised 1 Failure to select a safer bariatric procedure for patients with a hernia 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
Monique Susanna WHITBREAD · 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
Monique Susanna Whitbread died from pulmonary aspergillosis and sepsis following intra-abdominal complications related to bariatric procedures, including a gastric bypass performed for obesity. The report raised concern that freeing omental fat during the bypass may have allowed her hernia to strangulate, and noted that sleeve gastrectomy may be safer for patients with a hernia.
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 University College Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to select a safer bariatric procedure for patients with a hernia
Wider context from the report “You performed a gastric bypass on 9 January 2014. At operation, you freed a plug of omental fat to perform the bypass, but it seems that this later allowed Ms Whitbread’s hernia to strangulate , and she died ultimately from the consequences of this.
You indicated to me at inquest that, in future, you will perform a sleeve gastrectomy rather than a gastric bypass on those patients who have a hernia . Although the surgery is not necessarily quite as effective, you believe it to be safer in this situation .
” 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