Report evidence summary
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
× 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 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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.
” Is this part of a recurring concern? Yes — Unreliable hospital discharge processes .
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 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.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
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 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 .
” Is this part of a recurring concern? Yes — Unreliable hospital discharge processes .
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 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.
” Is this part of a recurring concern? Yes — Unreliable management of urinary catheters .
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 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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.
” Is this part of a recurring concern? Yes — Unsafe continence care and management .
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 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.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
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 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.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
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 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.
” Is this part of a recurring concern? Yes — Unreliable bowel monitoring and charting .
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 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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
×
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 Educate ward nurses on patient moves, site-manager information requirements and transfer documentation.
Verbatim wording from the response “g) educational sessions with ward nurses to explore the rationale for moving patients. This will include both emphasis on the need to provide adequate information to the clinical site manager if consideration is being given to moving a patient (especially late at night), and teaching on the documentation requirements (including completion of the transfer document), should it be unavoidable for a patient to be moved from one ward to another. This will help ensure that adequate information accompanies any patient who, for whatever reason, has to be moved from one ward to another.” Source location 2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
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 Recruit a Clinical Nurse Practice Educator based on Twineham ward to support staff, including communication training.
Verbatim wording from the response “a) the recruitment of a new Clinical Nurse Practice Educator based on Twineham ward. This postholder is able to assist staff with a range of issues, including providing training on all aspects of communication (written and verbal)” Source location 2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
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 Develop and deliver a Twineham ward training package on accurate documentation and the consequences of poor documentation.
Verbatim wording from the response “c) joint development of a training package for all the staff based on Twineham ward, by the senior physiotherapy and nursing staff, to assist with accurate and detailed documentation. This includes a specific focus on the potential consequences of poor documentation” Source location 2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
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 Discuss avoiding late-night patient moves with clinical site managers responsible for bed allocation.
Verbatim wording from the response “In addition, there have been discussions with the clinical site managers, who are the senior nurses on duty 24 hours a day on each site, with responsibility for allocating beds for patients. These staff are well aware that it is undesirable to move any patient late at night, even though this may be unavoidable in order to accommodate patients admitted through the Emergency Department.” Source location 2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
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 Strengthen senior medical review requirements, including consultant reviews, daily review of sick patients, junior attendance and documentation of discussions.
Verbatim wording from the response “h) review of senior medical input on Twineham ward. The Clinical Director for the musculoskeletal service has emphasized that every patient on Twineham ward should normally be seen by a consultant orthopaedic surgeon or orthogeriatrician at least four times a week (including one day at the weekend), including a conversation with the patient and review of their progress with them. Any patient who is sick should be seen daily by a consultant. The junior medical staff have been reminded that they must attend with the consultant, and should record every such discussion in the notes, if the consultant does not do this themselves” Source location 2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
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 Increase trained and therapy-support physiotherapy staffing to reduce missed planned physiotherapy and prioritise patients missed the previous day.
Verbatim wording from the response “d) increased physiotherapy staffing (both trained and therapy support staff), reducing the occasions when it is not possible for a patient to have physiotherapy as planned, with recognition that any patient that is not seen on one day must become one of the highest priorities for the next day” Source location 2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Integrate the fractured-neck-of-femur service at Princess Royal Hospital to provide continuity and avoid cross-site communication failures.
Verbatim wording from the response “May we start by expressing our sympathy on their sad loss to the family of Mr Geerts. Since he died, considerable changes have been implemented within this Trust specifically relating to the management of patients who have suffered a fractured neck of femur. Instead of routinely operating at the Royal Sussex County Hospital and then transferring the patients to the Princess Royal Hospital for rehabilitation, the whole service is now provided at the Princess Royal Hospital. This provides greater continuity for the patients, and indeed for the staff, and eliminates an opportunity for confusion or breakdown in communication between staff working in different places.” Source location 2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce integrated documentation for all clinical staff treating patients on Twineham ward.
Verbatim wording from the response “b) introduction of integrated documentation for use by all the clinical staff treating each patient on the ward” Source location 2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
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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. 3 1 Review progress of the fractured-neck-of-femur service at Princess Royal Hospital and use further learning to refine and develop it.
Stated by University Hospitals Sussex NHS Foundation Trust Stated plannedThe respondent said that this action was planned when they made their response on 24 June 2015. View source 2 Provide a senior physiotherapy lead based on Twineham ward.
Stated by University Hospitals Sussex NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 24 June 2015. View source 3 Strengthen nurse–physiotherapist liaison to maintain continuity of nursing care when physiotherapists are absent.
Stated by University Hospitals Sussex NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 24 June 2015. View source
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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 Review progress of the fractured-neck-of-femur service at Princess Royal Hospital and use further learning to refine and develop it.
Verbatim wording from the response “We will be reviewing the progress of these changes in services for people with fractured necks of femur at the Princess Royal Hospital, and any further learning will be used to refine and develop the new service further.” Source location 2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
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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 Provide a senior physiotherapy lead based on Twineham ward.
Verbatim wording from the response “f) provision of a senior physiotherapy lead member of staff based on Twineham ward” Source location 2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
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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 Strengthen nurse–physiotherapist liaison to maintain continuity of nursing care when physiotherapists are absent.
Verbatim wording from the response “e) closer liaison between nurses and physiotherapists, about relevant continuity of care by nurses for patients at times when physio-therapists are not present” Source location 2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
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The published report provides this section by reference to another part of the report.