Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate clinical documentation hindering patient care understanding
The earlier warning
Mary Jones · 30 Sept 2019 · Alison Mutch, Manchester (South)
“The documentation within the nursing notes, particularly the fluid charts was poor quality, making it difficult to understand what had happened in relation to the hydration of Mrs [name redacted]”
What was promised
Stated action 1 · response to Evelyn Ross (27 Apr 2020) · stated timescale: March 2020
“The Trust has an established process in place to review nursing workforce establishments and skill mix for all wards. This utilises an evidence-based triangulated approach to determine nurse staffing levels and skill mix, that reflect patient acuity and dependency requirements to inform workforce planning. The Safer Nursing Care Tool (SNCT) is utilised to gather patient acuity and dependency data over a four-week period. Ward 6 completed data collection periods in March, June and September 2019 and”
judiciary.uk/…/2020-0106-Response-from-Manchester-University-NH…
What recurred
- 27 Apr 2020 · Evelyn Ross · Alison Mutch · Identical hazard · confidence 0.90 (high)
- 9 May 2025 · Janet Anderson · Alison Mutch · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Mary Jones · 30 Sept 2019
“The documentation within the nursing notes, particularly the fluid charts was poor quality, making it difficult to understand what had happened in relation to the hydration of Mrs [name redacted]”
Later · Evelyn Ross · 27 Apr 2020
“During the course of the inquest the documentation relied on by the trust was lacking in detail and meant that it was difficult to understand her condition at key points or to understand the rationale for decisions.”
What happened next
No web check of the stated actions has been published for this chain.