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Selected Investigations Completed April - September 1997 > Part I, Case no. E.0826/96-97
Matters considered: Failure adequately to monitor and maintain a patient's intravenous infusion
Complaint against: Homerton Hospital NHS Trust, London
Summary of case
A woman's mother died in Homerton Hospital, East London on 29 January 1995. The night before she died, and also early the following morning, her family noticed that the patient's fluid bag for her intravenous infusion was empty. They thought it was the same bag. The woman's sister complained to the chief executive of the Trust about her mother's care, but remained dissatisfied with the explanations given, and complained to me.
Findings
The woman's mother's fluid charts showed that her fluid bag was replaced at 10.30 pm on 28 January and again at 8.40 am on 29 January. I found that the family had, on both occasions, seen empty bags which were about to be replaced. I noted evidence that the woman's mother was not dehydrated, and I did not uphold the complaint. I found some shortcomings in the record keeping of the patient's fluid intake.
Remedy
The Trust have introduced new fluid prescription charts, and have agreed to make sure that all nursing staff complete fluid balance charts fully and accurately.
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