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recurance

David Kerr

22 Apr 2020 · Coroner Jason Wells · Manchester South

The coroner's concerns

  1. 1. medical care on ward D2

    “DK's medical care on ward D2 was poor and probably contributed to his death”
  2. 2. dehydration

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

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

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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David Kerr · Recurance