“There were incomplete records kept and especially in respect of the fluid balance chart…”
Dated 21 Nov 2016, from the coroner for Mid Kent and Medway. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 16 Jan 2017. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated21 Nov 2016
- Deadline16 Jan 2017
- Published on judiciary.uk21 Nov 2016
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Medway NHS Foundation TrustNamed in the report as “Medway NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 16 Jan 2017. A reply may have been sent and not yet published. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— 1) There were incomplete records kept and especially in respect of the fluid balance chart thereby rendering it an ineffective diagnostic tool. 2) 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)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. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation have the power to take such action. |7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 16" of January 2017 . I, the coroner, may extend the period.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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