Missing prescription and fluid balance documentation
Blackpool Teaching Hospitals NHS Foundation Trust received 2 coroners' reports about this hazard between 19 Oct 2020 and 23 Jan 2025.
They came from 2 different coroners. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 5 specific actions.
The story, report by report
Spacing grows with the time between reports.
“whilst fluids had been prescribed, no prescription chart or fluid balance chart had been completed.”
Original on judiciary.uk ↗ Blackpool Teaching Hospitals NHS Foundation Trust responded, stating 5 specific actions.Response (PDF) ↗
“the Medical Leadership Forum has agreed a policy for Internal Professional Standards for Blackpool Teaching Hospitals NHS Foundation Trust”
“the Trust monitors completion of the NEWS2 charts through spot audits.undertaken by the Matrons and Ward Managers”
3 more stated actions in the Promises tab.
- 4 years 3 months laterClosely relatedConfidence 0.90 · higha different coroner
“Fluid balances are not being monitored as effectively as they ought to be;”
Original on judiciary.uk ↗ Blackpool Teaching Hospitals NHS Foundation Trust responded.Response (PDF) ↗
- All reports to Blackpool Teaching Hospitals NHS Foundation Trust
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2020 → 2025Brian Kneale4 years 3 months after Douglas Owens · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with the documentation and monitoring of fluid balances for patients. The earlier report notes missing prescription/fluid balance charts when fluids are prescribed, while the later report states fluid balances are not being monitored effectively.
Douglas Owens · 19 Oct 2020
“whilst fluids had been prescribed, no prescription chart or fluid balance chart had been completed.”
Original on judiciary.uk ↗ Brian Kneale · 23 Jan 2025
“Fluid balances are not being monitored as effectively as they ought to be;”
Original on judiciary.uk ↗
Stated action
“the Medical Leadership Forum has agreed a policy for Internal Professional Standards for Blackpool Teaching Hospitals NHS Foundation Trust”
Stated action
“the Trust monitors completion of the NEWS2 charts through spot audits.undertaken by the Matrons and Ward Managers”
Stated action
“the Head of the Emergency Department and the Matron will ensure senior clinical staff will undertake regular spot audits / huddles”
Stated action
“the Trust and the Emergency Department (ED) have committed to major improvement projects and programmes to improve the 'recognise and act' element in the care and treatment of a deterioriating patient”
Stated action
“the Quality Improvement Strategy describes a new Deteriorating Patient Collaborative, to test ways of working that will help teams to recognise and respond to the clinical deterioration of patients”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Blackpool Teaching Hospitals NHS Foundation Trust at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2020 → 2025 | 0.75 | 0.27 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.