“(brief summary of matters of concern) [1] At the time of Mr Blewitt's death there was no…”

The coroner’s concerns

(brief summary of matters of concern) [1] At the time of Mr Blewitt's death there was no effective, reliable recording of intravenous fluids administered to patients in the emergency department. That in my view has potential to represent a threat to the safety and lives of patients suffering with a wide variety of different conditions. The author of the SI report who attended to give evidence did not, at the time of Inquest 8 months later, was unable to demonstrate that the Trust had remedied that. [2] Despite the 8 month interval between Mr Blewitt's death and the Inquest the issues of concern had not been brought to the attention of hospital authorities. [3] On arrival at the ED a triage nurse summarised the communication from the urgent care centre. The triage nurse missed important points during the transcription. The attending doctor did not concern himself to look at the communication himself. [4] I was concerned that the treating doctor made a contemporaneous note on the 9th July 2022 at Mr Blewitt's first presentation which failed to record the major presenting symptom, diarrhoea with faecal incontinence, which Mr Blewitt had communicated to the urgent care doctor who in turn had included that in her notes and letter to the ED. The treating doctor did record a flatly contradictory note to the effect there was no change in bowel habit. [5] The Incident Investigation Report which is in part designed to assist with learning from adverse events was of a generally poor standard. There was a failure to consider issues in Regulation 28 – After Inquest Document Template Updated 30/07/2021 detail; there was a failure to challenge the statements of clinicians where there were obvious contradictions between statements made and the medical record; there was a failure to put in place measures to correct and monitor prescribing clinicians failure to sign off on IV fluid prescriptions so that the contemporaneous record would be available for clinicians coming after them and they could see whether a patient had satisfactory or unsatisfactory fluid management. The only record in the case was a typed note by a junior doctor to the effect that it was thought Mr Blewitt had received 2 litres of fluid since arrival.

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, 2023-0207

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0