George Kearsey

Private & Confidential 

Mr G Irvine 
HM Senior Coroner 
Walthamstow Coroner’s Court 
Queens Road 
London     
E17 8QP 

Legal Services 
Queen's Hospital 
Rom Valley Way, Romford, RM7 0AG 

Phone: 01708 435 000 
www.bhrhospitals.nhs.uk 
  @BHRUT_NHS 

11 April 2023 

Dear Sir, 

Regulation 28 Report on the death of George Kearsey   

Thank you for your Regulation 28 Report of 09 February 2023. The Trust has carefully considered 
the concerns raised by HM Senior Coroner in his Regulation 28 Report and guidance has been 
sought from various specialists within the Trust as to the concerns raised by the Learned Coroner 
in his Regulation 28 Report.   

The matters of concern identified in the Regulation 28 report are:  

• 

IV fluids were not administered consistently.  The longest period in which fluids were not 
administered was 17 hours and 45 minutes.   

•  Contrary to Trust policy, fluid balance charts were not in place to assess Mr Kearsey’s fluid 

intake and output.  

•  Clinical  records  were  poorly  maintained,  resulting  in  an  unclear  picture  of  fluid 

administration.   

•  Consultant led ward rounds did not adequately review fluid monitoring.   

Trust’s Response: 

In order to address the concerns you have identified, the Trust have carried out / are implementing 
the following:  

•  Cross site audits have been completed on COTE (Care of the Elderly) wards on a random 
basis to understand a cross section of compliance with fluid management with no notice 
given to the ward in advance of the audit.  The audits capture patients who are on fluid 
restriction,  patients  requiring  oral  and  intravenous  hydration,  parenteral  nutrition  and 
output  monitoring,  whether  the  intake  and  output  is  entered  on  Careflow  Vitals  and 
appropriate  action  taken  as  necessary.  The  audits  were  completed  by  senior  nursing 
teams (Matrons, Ward Managers, Practice Development Nurses).  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The division will continue to monitor this (three times a week for the next 6 months on every 
COTE ward) to ensure that fluids are recorded on Careflow Vitals and that the fluid balance  
is maintained appropriately. Learning and findings from the audit are shared verbally with 
the teams.  

•  Peer audits are being undertaken - The first phase of the audits has been completed. The 
nursing staff on all wards have been informed of the expectation for fluid monitoring and 
recording this on Careflow Vitals. We have also introduced peer audits where ward teams 
will  conduct  random  audits  on  other  COTE  wards  for  the  next  6  months.  The  format  of 
these audits will mirror those conducted by the wards. The feedback from these audits will 
be  shared  with the  matron  and  ward manager of  that area and  relevant  action taken,  if 
required. An example is if a patient is on fluid restriction and their fluid intake has not been 
recorded on careflow vitals. This can have an adverse effect on the patient’s treatment.  
The ward manager will discuss the importance of fluid management and monitoring with 
staff. The peer audits will commence in April 2023 and will run concurrently with the 3 times 
a  week  audits.  The  results  of  these  audits  will  also  be  presented  at  divisional  weekly 
(tracker) governance meetings. Ward Managers and Matrons will also share the results of 
these audits during daily huddles.  

•  The findings and the learning from the audits will be presented in the monthly divisional 
QGSG  (Quality  Governance  Steering  Group)  meeting  which  is  well  attended  by  both 
medical and nursing teams. This will be completed by 30 June 2023.  

•  Nursing  staff  have  received  additional  training  on  Careflow  vitals  to  reinforce  the 
importance of staff compliance with the Trust policy on the completion of fluid monitoring. 
In addition, nursing staff have had 1:1 sessions with matrons and practice development 
nurses. Since the implementation of the audits,  an improvement has been noted in fluid 
balance monitoring. For example, on 15 February 2023, Clementine A only scored 70% 
compliance. The gaps were discussed and addressed immediately with the nursing teams. 
This  improved  the  compliance  on  Clementine  A,  with  audits  now  showing  100% 
compliance.   

•  We identified that some medical staff were not familiar with using Careflow Vitals to access 
patients’ fluid balance. Face to face training, by the Careflow team has now been provided 
for all medical staff, to ensure they are all aware of how to access the fluid balance  on 
Careflow  Vitals.  Medical  staff  were  all  made  aware  that  paper  fluid  charts  will  not  be 
completed in the future.    

•  Following the inquest, it was highlighted, during the Divisional Quality and Safety Meeting 
in  March  2023,  that  consultants  should  review  patient  fluid  monitoring  information  on 
Careflow vitals.  This was followed up by an email sent by the Quality and Safety team on 
30 March 2023 to all of the COTE medical staff to ensure that all medical staff are aware 
that  fluid  monitoring  will  be  recorded  on  Careflow  Vitals  and  that  assistance  should  be 
sought from the nurse in charge, Ward Manager or Matron if they were unable to access 
that information. This will be discussed again at the April 2023 Divisional Quality and Safety 
meeting. The Matrons will be giving feedback about the audits they have completed, and 
any issues identified as part of the ongoing monitoring.  

•  Fluid monitoring is now consistently reviewed at Consultant Led Ward Rounds. Following 
Mr  Kearsey’s  inquest  hearing,  clinical  leads  from  the  geriatric’s  division  worked  with  IT 
colleagues  to  ensure  a  comprehensive  understanding  of  VitalPack  as  well  as  ensuring 
there was clarity in knowing how to access fluid charts. This was shared with all medical 
staff  in  the  division  via  the  divisional  governance  meeting.  The  same  information  was 

 
 
 
 
 
 
 shared  at  board  rounds  which  are  the  Trust’s  multidisciplinary  patient  review  meetings. 
They take place twice a day and all doctors on every ward are now familiar with electronic 
fluid charts on VitalPack.  

•  The Trust’s Careflow vitals lead will be responsible for the teaching presentation on the 
use of careflow for fluid management at the next clinical review group (CRG) (date to be 
confirmed).  Information about use of Careflow for fluid management was shared via the 
CMO  (chief  medical  officer)  newsletter.  In  the  March  edition  of  the  CMO  newsletter,  Dr 
Daniels wrote: We need to ensure we review fluids in all patients receiving IV fluids daily, 
we need to ensure we write up fluids in a timely manner. We need to ensure that we always 
review  fluid  balance  in  a  patient  on  IV  fluids  on  the  ward  round.  CMO  newsletters  are 
monthly  newsletters  posted  on  ‘workspace’  -  an  online  platform  for  all  staff,  including 
nursing and medical staff, which has been designed to replace the Trust’s intranet. 

•  Training material has been produced on BEST for all aspects of Careflow vitals including 
fluid  management  which  can  be  accessed  by  all  staff.  BEST  is  an  online  application 
available on the TRUST intranet where staff are able to access training and to record the 
training they have completed. A quick ‘how to’ video targeting doctors has been developed 
and was published on workspace on 29 March 2023. These videos show where to find 
fluid management information and all staff are able to access.  

In addition to the above a Clinical Safety Assessment is to be carried out by the end of April 2023. 
The purpose of the assessment is to identify any hazards, risks or issues to mitigate any issues 
of not being able to enter data or view fluid balance records. Thirteen staff completed the clinical 
safety (CS) officer training on the 29th /30th March. The CS role is in the recruitment process and 
will be interviewed for on the 18th April 2023. 

The Trust have taken the issues identified by the Learned Coroner very seriously and have taken 
positive action to address those issues.  Further steps are still being taken as we have detailed 
in  this  letter  and  we  hope  that  this  allays  any  concerns  the  Coroner  has  regarding  the  issues 
identified in the PFD report.   

I would be happy to meet to discuss this response if that would be helpful to the Coroner.   

Yours sincerely, 

Chief Medical Officer

From Minister Caulfield MP  
Parliamentary Under Secretary of State  
Minister for Mental Health and Women’s Health Strategy  
Department of Health and Social Care 

39 Victoria Street  
London  
SW1H 0EU  

13 May 2024  

Mr Graeme Irvine  
East London Coroner’s Court 
Queens Road  
Walthamstow  
E17 8QP 

Dear Mr Irvine,   

Thank you for your letter of 9 February 2023 about the death of George Kearsey. I am 
replying as Minister with responsibility for Patient safety.      

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Kearsey’s 
death, and I offer my sincere condolences to their family and loved ones.  The circumstances 
your report describes are very concerning and I am grateful to you for bringing these matters 
to my attention. Please accept my sincere apologies for the significant delay in responding to 
this matter  

The report raises concerns about the administration of IV fluids and the appropriate process 
of monitoring and documentation not being followed.   

In preparing this response, Departmental officials have made enquiries with NHS England 
and the Care Quality Commission (CQC).  

I am aware that Barking, Havering and Redbridge University Hospitals NHS Trust provided a 
response to your Regulation 28 report in April 2023, outlining the steps taken in response to 
the concerns identified.   

Following further enquires with NHS England, the trust has provided the following update:   

•  Audits have been completed in Geriatrics and Frailty wards and the findings were 
presented at the monthly Clinical Group Quality & Safety meeting and the Quality 
Governance Steering Group. Across the 9 audited areas, over the period of three 
months (March, April and May 2023), the audits demonstrated that 87% of patients’ 
fluid charts were completed, recorded on vital pac and available to review. Each 
patient that did not have fluid chart completed and recorded on vital pac (due to a 
new admission to the ward or if any had not been documented as expected) was 
reviewed. Audit results feedback was provided to the nursing staff by the relevant 
Ward Managers or Practice Development Nurses.   

  
  
  
  
  
  
  
  
 
 
  
  
  
  
  
  
  
  
  
 •  The Quality and Safety Advisor completed a random spot check audit in June at 
Queen’s Frailty Unit and Beech Frailty Unit to check that fluid charts were being 
completed and were available on vital pac. A total of 18 patients’ records were 
audited and all had completed and detailed fluid charts in place and recorded on vital 
pac. Random spot check audits are continuing.  

•  The Clinical Safety Assessment on Vital pack was completed to ensure accurate data 

input and data availability.  

•  The Clinical Group have met George Kearsey’s daughters as part of the complaint 

process and resolved their concerns. They have also been invited to attend Geriatrics 
and Frailty ward managers forum to share their story and provide face-to-face 
feedback to the nursing staff to highlight the importance of fluid monitoring.  

The CQC continues to discuss and monitor the progress of actions taken during their regular 
engagement meetings with the Trust and how the Trust embeds learning remains a matter for 
their attention.  

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Best Wishes,   

MARIA CAULFIELD