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 Delays in prescribing food supplements
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 maintain patient warmth
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 senior clinical review
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 weigh the patient
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 the daily catheter care bundle
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 remove an IV cannula after 72 hours
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 record NEWS scores on drug charts
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 prescribe and administer prescribed Sertraline
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 falls-risk wristbands for patients at risk of falling
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” Is this part of a recurring concern? Yes — Inadequate control of falls risks .
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 Incomplete and ineffective clinical handover
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” Is this part of a recurring concern? Yes — Unreliable clinical handover 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 escalate NEWS scores to doctors
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 required personal and oral care
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 Pressure damage to the hips and buttocks
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” Is this part of a recurring concern? Yes — Inadequate management of pressure ulcers .
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 food intake
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 specialling when required
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” Is this part of a recurring concern? Yes — Failure to provide required specialling .
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 allergy wristbands for patients with known allergies
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 the malnutrition assessment tool
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” Is this part of a recurring concern? Yes — Inadequate management of malnutrition risk .
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 use the required trolley for patient transfer
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 patient care plans
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” Is this part of a recurring concern? Yes — Unreliable care-planning 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 complete daily oral assessments
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 fluid intake and output
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 handling assessments
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” Is this part of a recurring concern? Yes — Unsafe moving and handling of patients .
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 Incomplete and poor repositioning records
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 bowel movements
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 patient identity wristbands
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 Increase permanent Acute Medical Unit staffing, including matron input, an additional senior nurse and a support assistant role.
Verbatim wording from the response “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:” Source location 2015-0178-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 Improve information quality and clinical handover when patients transfer from the Acute Medical Unit to specialist wards.
Verbatim wording from the response “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:” Source location 2015-0178-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 Monitor documentation more closely and provide nurses with real-time feedback.
Verbatim wording from the response “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:” Source location 2015-0178-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 Assign a critical care outreach nurse to link the Acute Medical Unit with critical care services.
Verbatim wording from the response “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:” Source location 2015-0178-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 Review and condense Acute Medical Unit documentation into multidisciplinary paperwork that directs care and reduces duplication.
Verbatim wording from the response “Extensive and complex work is also being undertaken to” Source location 2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Open published response
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. 7 1 Appoint a practice educator dedicated to teaching and supporting Acute Medical Unit staff in the workplace.
Stated by University Hospitals Sussex NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 7 May 2015. View source 2 Participate as a pilot site in the national FrailSafe project to improve care for frail patients.
Stated by University Hospitals Sussex NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 7 May 2015. View source 3 Develop specialist patient areas and associated staffing skills for particularly sick, confused or dementia-affected patients.
Stated by University Hospitals Sussex NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 7 May 2015. View source 4 Use additional methods to obtain bank and agency staff to fill vacant shifts when necessary.
Stated by University Hospitals Sussex NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 7 May 2015. View source 5 Improve Acute Medical Unit signs and layout to help confused patients orient themselves and settle into the environment.
Stated by University Hospitals Sussex NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 7 May 2015. View source 6 Establish a working group addressing practices and documentation to ensure sick patients receive timely, appropriate attention.
Stated by University Hospitals Sussex NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 7 May 2015. View source 7 Continue monitoring the effectiveness of introduced changes in addressing the identified concerns.
Stated by University Hospitals Sussex NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 7 May 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 Appoint a practice educator dedicated to teaching and supporting Acute Medical Unit staff in the workplace.
Verbatim wording from the response “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:” Source location 2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Open published response
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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 Participate as a pilot site in the national FrailSafe project to improve care for frail patients.
Verbatim wording from the response “Extensive and complex work is also being undertaken to” Source location 2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Open published response
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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 Develop specialist patient areas and associated staffing skills for particularly sick, confused or dementia-affected patients.
Verbatim wording from the response “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:” Source location 2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Open published response
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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 Use additional methods to obtain bank and agency staff to fill vacant shifts when necessary.
Verbatim wording from the response “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:” Source location 2015-0178-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 Improve Acute Medical Unit signs and layout to help confused patients orient themselves and settle into the environment.
Verbatim wording from the response “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:” Source location 2015-0178-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 Establish a working group addressing practices and documentation to ensure sick patients receive timely, appropriate attention.
Verbatim wording from the response “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:” Source location 2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Open published response
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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 Continue monitoring the effectiveness of introduced changes in addressing the identified concerns.
Verbatim wording from the response “Thank you once again for raising these matters with us. We confirm the Trust remains committed to a continuing programme to address the concerns you describe and to monitor the effectiveness of the changes introduced in resolving these issues.” Source location 2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
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Information checked against the published report and official responses