Recurance · prevention of future deaths reports

Pre-inquest brief

Missing prescription and fluid balance documentation

Organisation: Blackpool Teaching Hospitals NHS Foundation Trust · Generated: 26 Oct 2026

The earlier warning

Douglas Owens · 19 Oct 2020 · Tim Holloway, Blackpool & Fylde

“whilst fluids had been prescribed, no prescription chart or fluid balance chart had been completed.”

Stated action 1 · response to Douglas Owens (19 Oct 2020) · stated timescale: none stated

“the Medical Leadership Forum has agreed a policy for Internal Professional Standards for Blackpool Teaching Hospitals NHS Foundation Trust”

Stated action 2 · response to Douglas Owens (19 Oct 2020) · stated timescale: none stated

“the Trust monitors completion of the NEWS2 charts through spot audits.undertaken by the Matrons and Ward Managers”

Stated action 3 · response to Douglas Owens (19 Oct 2020) · stated timescale: none stated

“the Head of the Emergency Department and the Matron will ensure senior clinical staff will undertake regular spot audits / huddles”

2 further stated actions are listed on the full chain page.

23 Jan 2025 · Brian Kneale · Alan Wilson · Closely related · confidence 0.90 (high)

The clearest link, quoted from both reports:

Earlier · Douglas Owens · 19 Oct 2020

“whilst fluids had been prescribed, no prescription chart or fluid balance chart had been completed.”

Later · Brian Kneale · 23 Jan 2025

“Fluid balances are not being monitored as effectively as they ought to be;”

No web check of the stated actions has been published for this chain.