Keith Fleming

1. 1. dehisence of bowel anastomosis leading to internal infection

   “The deceased underwent an elective reversal in January 2013 of an illiostomy performed in 2007 due to a cancer within the lower bowel”

2. 2. lack of vital sign monitoring

   “The care plan devised during this period of community nursing care did identify a need to record temperature and blood pressure readings. Unfortunately these readings were not carried out and accordingly were not recorded”

3. 3. inadequate discharge planning

   “Surgical patients discharged to the community should be accompanied by a clear and direct plan for their expected level of care in the community”

4. 4. missed early warning signs

   “The recording of the deceased' vital signs, temperature and blood pressure would have provided some insight into the deceased' wellbeing and possibly given an early indication of a developing crisis”

5. 5. undetected ongoing bowel dehiscence

   “It is potentially possible to have been continuing in some degree for some considerable time”

6. 6. inadequate record keeping

   “Failure to maintain records, thereafter to properly interpret and action them, can it must be remembered be a basis for legal both Civil and Criminal”

No published response was found on judiciary.uk.