Theresa Button

“The staffing levels on Ward J83 should be reviewed, notwithstanding that they may currently meet the minimum levels prescribed. The ward handles a challenging cohort of patients with liver disease who have complex needs which merit close nursing attention.”

“Evidence taken at the Inquest revealed concerns that treatment plans instituted by clinicians were not always fully or effectively implemented as the staff were often too busy, particularly at night. Example included not hoisting an immobile lady out of bed onto a chair before mealtimes'and then having time to encourage her to eat.”

“In this case the deceased was frail and losing weight due to not eating. A family member witnessed her food being left on her tray whilst she was laid flat and hence unable to access it with the result that it went cold and she did not eat, despite the concern relating to her nutritional condition.”

“Insufficient time was available for the nursing staff and clinicians to explain treatment decisions to family members. An example given at the Inquest related to a decision to prescribe anti-depressant medication without the family being informed of any psychiatric involvement.”

“Contemporaneous nursing records were not always maintained; for example relating to food and fluid intake (even though nutrition was a matter of concern to the treating clinicians).”