PFD report

DAVID CRAIG KERR · Prevention of Future Deaths report

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Issued 22 Apr 2020•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
13

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Failure to perform clinical observations at appropriate frequency for sick patients
    Part of recurring concern: Unreliable patient observation arrangements
  2. Inadequate provision of fluids to seriously unwell patients
    Part of recurring concern: Failure to provide clinically required fluids
  3. Failure to produce a protocol for the frequency of observations in sick patients
    Part of recurring concern: Unreliable patient observation arrangements
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.9

  1. Action

    Deliver ward training on timely and accurate fluid-balance recording.

    Stated by Stockport NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2020.
  2. Action

    Produce daily NEWS2 reports for Matrons and Ward Managers and review whether appropriate action has been taken.

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2020.
  3. Action

    Reinforce accurate fluid-balance review and investigation of alternative causes of hypotension.

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The records showed positive, though declining, fluid balance, so the response disputes that the patient became increasingly dehydrated.

    Stated by Stockport NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to perform clinical observations at appropriate frequency for sick patients

Wider context from the report

“(3) There were few clinical observations on this sick patient. On 26th April, clinical observations were performed at 11.12 (MEWS 1) and 21.06 (MEWS 0). There were no clinical observations thereafter. No protocol was produced regarding the frequency of observations in sick patients on Ward D2. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate provision of fluids to seriously unwell patients

Wider context from the report

“(2) Between 24th and 26th April DK was allowed to become increasingly dehydrated; on 24th April he received a total of 300mls of fluid and the input/output chart was not filled in on 25th/26th April, despite the fact that he was seriously unwell. ”

Is this part of a recurring concern?

Yes — Failure to provide clinically required fluids.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to produce a protocol for the frequency of observations in sick patients

Wider context from the report

“(3) There were few clinical observations on this sick patient. On 26th April, clinical observations were performed at 11.12 (MEWS 1) and 21.06 (MEWS 0). There were no clinical observations thereafter. No protocol was produced regarding the frequency of observations in sick patients on Ward D2. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to complete input/output charts for seriously unwell patients

Wider context from the report

“(2) Between 24th and 26th April DK was allowed to become increasingly dehydrated; on 24th April he received a total of 300mls of fluid and the input/output chart was not filled in on 25th/26th April, despite the fact that he was seriously unwell. ”

Is this part of a recurring concern?

Yes — Unreliable recording of fluid balance information.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver ward training on timely and accurate fluid-balance recording.

Verbatim wording from the response

“In order to ensure compliance with best practice standards in Ward D2, the following actions are being taken:”

Source location

2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
Page 2 · response
Published 18 May 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Produce daily NEWS2 reports for Matrons and Ward Managers and review whether appropriate action has been taken.

Verbatim wording from the response

“• EWS daily reports are produced and sent via email to Matrons and Ward Managers with details for each area of patients who have scored on the NEWS2 which is reviewed to ensure appropriate action has been taken.”

Source location

2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
Page 3 · response
Published 18 May 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Reinforce accurate fluid-balance review and investigation of alternative causes of hypotension.

Verbatim wording from the response

“We have discussed his case with consultants across all clinical business groups and agreed the following Trust wide actions:”

Source location

2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
Page 2 · response
Published 18 May 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Roll out a Trust-wide fundamental-care framework containing common nutrition and hydration standards.

Verbatim wording from the response

“In addition, to ensure that learning is applied across the organisation, we have started the roll-out of a fundamental care framework across the Trust which includes common best practice standards for the management of nutrition and hydration.”

Source location

2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
Page 3 · response
Published 18 May 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Speak to staff involved and remind them to record and escalate observations appropriately and promptly.

Verbatim wording from the response

“In order to ensure compliance with best practice standards in Ward D2, the following actions are being taken:”

Source location

2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
Page 3 · response
Published 18 May 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Speak to staff involved and remind them to record fluid balances accurately.

Verbatim wording from the response

“In order to ensure compliance with best practice standards in Ward D2, the following actions are being taken:”

Source location

2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
Page 2 · response
Published 18 May 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Audit ward fluid-balance recording daily, provide feedback, and obtain external peer reviews for objectivity.

Verbatim wording from the response

“In order to ensure compliance with best practice standards in Ward D2, the following actions are being taken:”

Source location

2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
Page 2 · response
Published 18 May 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver ward training on observation recording and escalation under Trust policies and procedures.

Verbatim wording from the response

“In order to ensure compliance with best practice standards in Ward D2, the following actions are being taken:”

Source location

2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
Page 3 · response
Published 18 May 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Carry out a Trust-wide quality-improvement project covering hydration and nutrition using recognised improvement methodology.

Verbatim wording from the response

“In addition, to ensure that learning is applied across the organisation, we have embarked on a Quality Improvement Project focussed on all aspects of hydration and nutrition. This will be supported by the transformation team using recognised quality improvement methodology to achieve rapid and sustainable change.”

Source location

2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
Page 2 · response
Published 18 May 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The records showed positive, though declining, fluid balance, so the response disputes that the patient became increasingly dehydrated.

Verbatim wording from the response

“Between 24th and 26th April 2019, Mr Kerr was allowed to become increasingly dehydrated; on 24th April he received a total of 300mls of fluid and the input/output chart was not filled in on 25th/26th April, despite the fact that he was seriously unwell.”

Source location

2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
Page 2 · response
Published 18 May 2020

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

    Address consistent individual failings through formal recording and appropriate action.

    Stated by Stockport NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2020.
  2. 2

    Act on specialist advice or arrange consultant-to-consultant discussion to ensure timely treatment.

    Stated by Stockport NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2020.
  3. 3

    Improve weekend and bank-holiday clinical handovers.

    Stated by Stockport NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2020.
  4. 4

    Implement an action plan addressing identified Ward D2 improvement areas.

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2020.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The patient’s care was stable post-operatively, and the response does not accept that poor ward care probably contributed to his death.

    Stated by Stockport NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    Weekend and bank-holiday on-call medical cover was considered sufficient, with intervention provided when the patient required it.

    Stated by Stockport NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Address consistent individual failings through formal recording and appropriate action.

Verbatim wording from the response

“• Consistent individual failings will be addressed with the individual concerned, recorded in their personal file and appropriate actions taken.”

Source location

2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
Page 2 · response
Published 18 May 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Act on specialist advice or arrange consultant-to-consultant discussion to ensure timely treatment.

Verbatim wording from the response

“We have discussed his case with consultants across all clinical business groups and agreed the following Trust wide actions:”

Source location

2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
Page 2 · response
Published 18 May 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Improve weekend and bank-holiday clinical handovers.

Verbatim wording from the response

“We have discussed his case with consultants across all clinical business groups and agreed the following Trust wide actions:”

Source location

2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
Page 2 · response
Published 18 May 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement an action plan addressing identified Ward D2 improvement areas.

Verbatim wording from the response

“As part of the governance processes for the Trust, quality and care standards are monitored through the completion of audits which are reviewed at service level on a monthly basis and reported for further assurance through to the Trust’s Patient Safety and Quality Group (PSQG). These are quality metrics which are completed by the senior nursing team and are discussed at ward, business group and Trust quality meetings.”

Source location

2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
Page 3 · response
Published 18 May 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The patient’s care was stable post-operatively, and the response does not accept that poor ward care probably contributed to his death.

Verbatim wording from the response

“Mr Kerr’s medical care on ward D2 was poor and probably contributed to his death.”

Source location

2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
Page 1 · response
Published 18 May 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Weekend and bank-holiday on-call medical cover was considered sufficient, with intervention provided when the patient required it.

Verbatim wording from the response

“Mr Kerr did not receive an orthogeriatric review on the 22 April as this was a bank holiday weekend. Our usual practice, during weekend and bank holidays, is for the on-call team of doctors to provide care should the need for their intervention arise. In Mr Kerr’s case, this happened on 2 occasions. Further reviews were well detailed and patient-centric. He was reviewed from the 23 April 2019, by both the orthopaedic and orthogeriatric teams. The majority of the interventions were provided by the orthogeriatric team, as being physicians they are best placed to manage Mr Kerr’s medical conditions during his post-operative recovery and rehabilitation. He was also reviewed daily by the Orthopaedic team.”

Source location

2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
Page 1 · response
Published 18 May 2020

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026