Adrienne Studholme

“The fluid balance chart was found to be inaccurate. The evidence suggested that the accuracy of the chart relied on staff collecting and refilling empty water jugs and took no account of steps families may take to provide fluid”

“Evidence was heard that seizure activity would not be taken into account in assessing a patient in the Emergency Department unless it was witnessed by a member of staff”

“Evidence was heard that on readmission via the Emergency Department following recent surgery, there is no procedure requiring contact with the original treating department. In addition, there is no standard operating practice and no training ensuring that recent surgery is taken into account in a triage in the Emergency department”