David Kerr
22 Apr 2020 · Coroner Jason Wells · Manchester South
The coroner's concerns
1. medical care on ward D2
“DK's medical care on ward D2 was poor and probably contributed to his death”
2. dehydration
“Between 24th and 26th April DK was allowed to become increasingly dehydrated; on 24th April he received a total of 300mls of fluid and the input/output chart was not filled in on 25th/26th April, despite the fact that he was seriously unwell”
3. lack of clinical observations
“There were few clinical observations on this sick patient. On 26th April, clinical observations were performed at 11.12 (MEWS 1) and 21.06 (MEWS 0). There were no clinical observations thereafter. No protocol was produced regarding the frequency of observations in sick patients on Ward D2”