Emily Hewerdine
18 Aug 2025 · Coroner Elizabeth Didcock · Nottingham and Nottinghamshire
The coroner's concerns
1. inadequate hydration assessments and fluid balance charting
“That patients on the wards at Bassetlaw DGH will have inadequate assessments of hydration status, and have inaccurate and inadequate completion of fluid balance charts”
2. failure to identify deteriorating vulnerable patients
“That nursing assessments, particularly in very vulnerable patients, will not identify a deteriorating patient, thus preventing necessary escalation for medical assessment”
3. lack of clinical assessment before mental health referral
“That there continues to be a risk that no clinical assessment will be undertaken, in patients attending the Emergency Department at Bassetlaw DGH, prior to referral for a mental health assessment”
4. lack of clinical assessment before discharge
“that there continues to be a risk that no clinical assessment will occur in Emergency Department prior to a patients discharge home”