Linda Doherty

“There was no colorectal follow up in relation to the findings of the CT scan carried out on 2 December 2016 despite it being recommended by the Upper Gastro-Intestinal Multi-Disciplinary Team meeting at East Surrey Hospital on 20 December 2016”

“The Malnutrition Universal Scoring Tool (MUST) charts for [the deceased] were inaccurately scored during the period from 3 to 23 July 2017”

“The food charts for [the deceased] were not completed from 23 June to 12 July 2017 and again from 18 to 23 July 2017, despite Mrs [name redacted] being at risk of malnutrition”

“The MUST charts recorded that Mrs [name redacted] weight was 65kg in early June 2017 and had reduced to 57kg by 11 July 2017, yet the multi-disciplinary team caring for her did not recognize that she had lost a significant amount of weight until 1 August 2017”

“Mrs [name redacted] was placed on end of life care on 5 August 2017 by a Senior House Officer (SHO) following consultation with his Consultant, both of whom had had only limited prior involvement with her. The decision to place her on end of life care was made without any consultation with the Intensive Care team, to ascertain whether she would be suitable for intensive care, and without any consultation with the clinicians who had been treating her over the 4 course of the preceding three months”