“Despite being under the care of the medical team, Ms”

The coroner’s concerns

– 1) Despite being under the care of the medical team, Ms. Stevens did also receive input from the surgical team. Her situation was further complicated by the fact that for most of her admission she was placed as a medical outlier on 1 a surgical ward. In the event, no one consultant was in overall charge of her care, which meant that the issues identified in this case were not picked up on. I heard evidence that there was no policy in place at the Trust to give guidance as to how this sort of situation should be resolved, but instead that it was expected that consultants would liaise with each other in order to do so. That did not happen in this case; 2) No doctor providing care for Ms. Stevens followed the established principle that the prescription of intravenous fluids for a patient must be accompanied by regular testing of electrolytes. In Ms. Stevens’ case, this was particularly important because her baseline sodium level was low anyway, so the overprescription of fluids put her at greater risk of hyponatraemia; 3) There was no proper recording of Ms. Stevens’ fluid intake and output on fluid balance charts for most of her hospital admission. For the reasons set out at 2) above, this was vitally important in her case; 4) Ms. Stevens’ hospital notes revealed evidence of the routine “copying and pasting” of out-of-date care plans by previous doctors. This meant that the next person reading her notes would be left with an erroneous view of her current care plan.

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, 2024-0512

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8 Oct 2026

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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