Mathew Bailey
12 Aug 2026 · Coroner David Reid · Worcestershire
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of fluid monitoring for kidney infection patients
“charts monitoring his intake and output of fluids should have been started and maintained, but were not. Nurses should do this as a matter of course for any patient with a urinary or kidney infection, and the doctors who reviewed him regularly during his 5 day admission should also have picked up on the fact that his fluids were not being monitored”
2. absence of VTE prophylaxis despite identified risk
“a venous thromboembolism ( VTE ) assessment was carried out, which identified that the deceased had an identified risk of suffering a VTE event and prescribed compression stockings to mitigate that risk. Both the nurses and doctors looking after the deceased should have picked up on this, but did not, with the result that the deceased was without VTE prophylaxis for the duration of his admission”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“No VTE assessment was ever made of Mrs [name redacted]. The explanation given oy was that staff were too busy to complete the form”
This report
“(b) a venous thromboembolism ( VTE ) assessment was carried out, which identified that the deceased had an identified risk of suffering a VTE event and prescribed compression stockings to mitigate that risk.”