Susanna Geraty
27 Jan 2015 · Coroner Karen Henderson · Surrey
The coroner's concerns
1. inadequate fluid balance monitoring
“Failure to assess, monitor and record post operative fluid balance”
2. inadequate nursing documentation
“Inadequate nursing records”
3. inadequate fluid balance charts
“Inadequate fluid balance charts”
4. failure to address family concerns
“Failure to respond to legitimate concerns raised by the family”
5. failure to recognise acute deterioration
“Failure to recognise an acutely unwell patient”
6. failure to consider dehydration cause
“Failure of the SI report to consider or acknowledge dehydration as a possible cause of acute renal failure”