George Kearsey
9 Feb 2023 · Coroner Graeme Irvine · East London
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. inconsistent IV fluid administration
“IV fluids were not administered consistently. The longest period in which fluids were not administered was 17 hours and 45 minutes.”
2. absence of fluid balance charts
“Contrary to Trust policy, fluid balance charts were not put in place to assess Mr [name redacted] fluid intake and output.”
3. poorly maintained clinical records
“Clinical records were poorly maintained , resulting in an unclear picture of fluid administration.”
4. inadequate fluid monitoring review
“Consultant-led ward rounds did not adequately review fluid monitoring.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“Clinical records were poorly maintained , resulting in an unclear picture of fluid administration.”
Later report
“During Mr [name redacted] ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent.”
Closely relatedConfidence 0.86 · high
This report
“IV fluids were not administered consistently. The longest period in which fluids were not administered was 17 hours and 45 minutes.”
Later report
“Intravenous fluids were commenced but these were not targeted against response. [the deceased] remained hypotensive and tachycardic despite the fluid administration.”
Responses
2023-0050-Response-from-Barking-Havering-and-Redbridge-University-Hospitals.pdf ↗· Barking
Stated action · completed
“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”
2023-0050-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · March, April and May 2023
“Audits have been completed in Geriatrics and Frailty wards and the findings were presented at the monthly Clinical Group Quality & Safety meeting and the Quality Governance Steering Group. Across the 9 audited areas, over the period of three months (March, April and May 2023), the audits demonstrated that 87% of patients' fluid charts were completed, recorded on vital pac and available to review. Each patient that did not have fluid chart completed and recorded on vital pac (due to a new admission”