PFD report

George Frederick Kearsey · Prevention of Future Deaths report

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Issued 9 Feb 2023•East London

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.

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Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
10

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 put fluid balance charts in place
    Part of recurring concern: Failure to reliably monitor patient fluid balancePart of recurring concern: Unreliable recording of fluid balance information
  2. Failure of consultant-led ward rounds to adequately review fluid monitoring
    Part of recurring concern: Failure to reliably monitor patient fluid balance
  3. Poor maintenance of clinical records of fluid administration
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care recordsPart of recurring concern: Unreliable recording of fluid balance information
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.7

  1. Action

    Train medical staff to access fluid balances in Careflow Vitals and discontinue completion of paper fluid charts.

    Stated by BHRUTStated completedThe respondent said that this action was complete when they made their response on 24 February 2023.
  2. Action

    Provide nursing staff with Careflow Vitals training and one-to-one fluid-monitoring support.

    Stated by BHRUTStated completedThe respondent said that this action was complete when they made their response on 24 February 2023.
  3. Action

    Require consultant-led ward rounds to review fluid monitoring in Careflow Vitals and reinforce this expectation through divisional communications.

    Stated by BHRUTStated completedThe respondent said that this action was complete when they made their response on 24 February 2023.

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 put fluid balance charts in place

Wider context from the report

“2. Contrary to Trust policy, fluid balance charts were not put in place to assess Mr Kearsey’s fluid intake and output. ”

Is this part of a recurring concern?

Yes — Failure to reliably monitor patient fluid balance; Unreliable recording of fluid balance information.

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Source evidence

How this individual concern was interpreted

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

PFD Monitor interpretation

Failure of consultant-led ward rounds to adequately review fluid monitoring

Wider context from the report

“4. Consultant-led ward rounds did not adequately review fluid monitoring. ”

Is this part of a recurring concern?

Yes — Failure to reliably monitor patient fluid balance.

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

Poor maintenance of clinical records of fluid administration

Wider context from the report

“3. Clinical records were poorly maintained, resulting in an unclear picture of fluid administration. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unreliable recording of fluid balance information.

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 administer IV fluids consistently

Wider context from the report

“1. IV fluids were not administered consistently. The longest period in which fluids were not administered was 17 hours and 45 minutes. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Train medical staff to access fluid balances in Careflow Vitals and discontinue completion of paper fluid charts.

Verbatim wording from the response

“• We identified that some medical staff were not familiar with using Careflow Vitals to access patients’ fluid balance. Face to face training, by the Careflow team has now been provided for all medical staff, to ensure they are all aware of how to access the fluid balance on Careflow Vitals. Medical staff were all made aware that paper fluid charts will not be completed in the future.”

Source location

Response from Barking, Havering and Redbridge University Hospitals
Page 2 · response
Published 24 February 2023

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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 nursing staff with Careflow Vitals training and one-to-one fluid-monitoring support.

Verbatim wording from the response

“• Nursing staff have received additional training on Careflow vitals to reinforce the importance of staff compliance with the Trust policy on the completion of fluid monitoring. In addition, nursing staff have had 1:1 sessions with matrons and practice development nurses. Since the implementation of the audits, an improvement has been noted in fluid balance monitoring. For example, on 15 February 2023, Clementine A only scored 70% compliance. The gaps were discussed and addressed immediately with the nursing teams. This improved the compliance on Clementine A, with audits now showing 100% compliance.”

Source location

Response from Barking, Havering and Redbridge University Hospitals
Page 2 · response
Published 24 February 2023

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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

Require consultant-led ward rounds to review fluid monitoring in Careflow Vitals and reinforce this expectation through divisional communications.

Verbatim wording from the response

“• Following the inquest, it was highlighted, during the Divisional Quality and Safety Meeting in March 2023, that consultants should review patient fluid monitoring information on Careflow vitals. This was followed up by an email sent by the Quality and Safety team on 30 March 2023 to all of the COTE medical staff to ensure that all medical staff are aware that fluid monitoring will be recorded on Careflow Vitals and that assistance should be sought from the nurse in charge, Ward Manager or Matron if they were unable to access that information. This will be discussed again at the April 2023 Divisional Quality and Safety meeting. The Matrons will be giving feedback about the audits they have completed, and any issues identified as part of the ongoing monitoring.”

Source location

Response from Barking, Havering and Redbridge University Hospitals
Page 2 · response
Published 24 February 2023

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 a Careflow fluid-management teaching presentation at the next Clinical Review Group meeting.

Verbatim wording from the response

“• The Trust’s Careflow vitals lead will be responsible for the teaching presentation on the use of careflow for fluid management at the next clinical review group (CRG) (date to be confirmed). Information about use of Careflow for fluid management was shared via the CMO (chief medical officer) newsletter. In the March edition of the CMO newsletter, Dr Daniels wrote: We need to ensure we review fluids in all patients receiving IV fluids daily, we need to ensure we write up fluids in a timely manner. We need to ensure that we always review fluid balance in a patient on IV fluids on the ward round. CMO newsletters are monthly newsletters posted on ‘workspace’ - an online platform for all staff, including nursing and medical staff, which has been designed to replace the Trust’s intranet.”

Source location

Response from Barking, Havering and Redbridge University Hospitals
Page 3 · response
Published 24 February 2023

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

Conduct peer fluid-monitoring audits between COTE wards and share results through governance meetings and daily huddles.

Verbatim wording from the response

“• Peer audits are being undertaken - The first phase of the audits has been completed. The nursing staff on all wards have been informed of the expectation for fluid monitoring and recording this on Careflow Vitals. We have also introduced peer audits where ward teams will conduct random audits on other COTE wards for the next 6 months. The format of these audits will mirror those conducted by the wards. The feedback from these audits will be shared with the matron and ward manager of that area and relevant action taken, if required. An example is if a patient is on fluid restriction and their fluid intake has not been recorded on careflow vitals. This can have an adverse effect on the patient’s treatment. The ward manager will discuss the importance of fluid management and monitoring with staff.”

Source location

Response from Barking, Havering and Redbridge University Hospitals
Page 2 · response
Published 24 February 2023

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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

Conduct and continue unannounced cross-site fluid-management audits on every COTE ward, monitoring Careflow Vitals recording and appropriate follow-up.

Verbatim wording from the response

“• Cross site audits have been completed on COTE (Care of the Elderly) wards on a random basis to understand a cross section of compliance with fluid management with no notice given to the ward in advance of the audit. The audits capture patients who are on fluid restriction, patients requiring oral and intravenous hydration, parenteral nutrition and output monitoring, whether the intake and output is entered on Careflow Vitals and appropriate action taken as necessary. The audits were completed by senior nursing teams (Matrons, Ward Managers, Practice Development Nurses).”

Source location

Response from Barking, Havering and Redbridge University Hospitals
Page 1 · response
Published 24 February 2023

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 clinical safety assessment to identify and mitigate hazards affecting entry or viewing of fluid-balance data.

Verbatim wording from the response

“In addition to the above a Clinical Safety Assessment is to be carried out by the end of April 2023. The purpose of the assessment is to identify any hazards, risks or issues to mitigate any issues of not being able to enter data or view fluid balance records. Thirteen staff completed the clinical safety (CS) officer training on the 29th /30th March. The CS role is in the recruitment process and will be interviewed for on the 18th April 2023.”

Source location

Response from Barking, Havering and Redbridge University Hospitals
Page 3 · response
Published 24 February 2023

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.3

  1. 1

    Present audit findings and learning at monthly divisional Quality Governance Steering Group meetings.

    Stated by BHRUTStated plannedThe respondent said that this action was planned when they made their response on 24 February 2023.
  2. 2

    Provide accessible Careflow fluid-management training materials and publish a targeted instructional video for doctors.

    Stated by BHRUTStated completedThe respondent said that this action was complete when they made their response on 24 February 2023.
  3. 3

    Recruit a clinical safety officer to support clinical safety management.

    Stated by BHRUTStated in progressThe respondent said that this action was in progress when they made their response on 24 February 2023.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The CQC is responsible for continuing to monitor the Trust’s actions and how it embeds learning.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Present audit findings and learning at monthly divisional Quality Governance Steering Group meetings.

Verbatim wording from the response

“• The findings and the learning from the audits will be presented in the monthly divisional QGSG (Quality Governance Steering Group) meeting which is well attended by both medical and nursing teams. This will be completed by 30 June 2023.”

Source location

Response from Barking, Havering and Redbridge University Hospitals
Page 2 · response
Published 24 February 2023

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

Provide accessible Careflow fluid-management training materials and publish a targeted instructional video for doctors.

Verbatim wording from the response

“• Training material has been produced on BEST for all aspects of Careflow vitals including fluid management which can be accessed by all staff. BEST is an online application available on the TRUST intranet where staff are able to access training and to record the training they have completed. A quick ‘how to’ video targeting doctors has been developed and was published on workspace on 29 March 2023. These videos show where to find fluid management information and all staff are able to access.”

Source location

Response from Barking, Havering and Redbridge University Hospitals
Page 3 · response
Published 24 February 2023

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 safety officer to support clinical safety management.

Verbatim wording from the response

“In addition to the above a Clinical Safety Assessment is to be carried out by the end of April 2023. The purpose of the assessment is to identify any hazards, risks or issues to mitigate any issues of not being able to enter data or view fluid balance records. Thirteen staff completed the clinical safety (CS) officer training on the 29th /30th March. The CS role is in the recruitment process and will be interviewed for on the 18th April 2023.”

Source location

Response from Barking, Havering and Redbridge University Hospitals
Page 3 · response
Published 24 February 2023

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 CQC is responsible for continuing to monitor the Trust’s actions and how it embeds learning.

Verbatim wording from the response

“The CQC continues to discuss and monitor the progress of actions taken during their regular engagement meetings with the Trust and how the Trust embeds learning remains a matter for their attention.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 24 February 2023

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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