Denis Plater
21 Nov 2016 · Coroner Kate Thomas · Mid Kent and Medway
The coroner's concerns
1. incomplete records of fluid balance
“There were incomplete records kept and especially in respect of the fluid balance chart thereby rendering it an ineffective diagnostic tool.”
2. misapplication of NEWS scoring system
“That a patient was placed in the care of Nurse who neither understood | the NEWS scoring system, did not apply it correctly and failed to escalate patient's condition in circumstances where she ought to have done so”
3. inadequate training and monitoring of agency staff
“That the Trust did not have in place a sufficiently rigorous or effective system for testing and monitoring the training, knowledge, understanding and compliance of agency staff.”
Responses
No published response was found on judiciary.uk.