Kelly Stevens

“Despite being under the care of the medical team, Ms [name redacted] did also receive input from the surgical team. Her situation was further complicated by the fact that for most of her admission she was placed as a medical outlier on a surgical ward. In the event, no one consultant was in overall charge of her care, which meant that the issues identified in this case were not picked up on. I heard evidence that there was no policy in place at the Trust to give guidance as to how this sort of situation”

“No doctor providing care for Ms [name redacted] followed the established principle that the prescription of intravenous fluids for a patient must be accompanied by regular testing of electrolytes. In Ms [name redacted]' case, this was particularly important because her baseline sodium level was low anyway, so the over prescription of fluids put her at greater risk of hyponatraemia”

“There was no proper recording of Ms [name redacted]' fluid intake and output on fluid balance charts for most of her hospital admission. For the reasons set out at 2) above, this was vitally important in her case”

“Ms [name redacted]' hospital notes revealed evidence of the routine”