Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0043, written 23 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Jan 2025 |
|---|---|
| Reference | 2025-0043 |
| Deceased | Brian Kneale |
| Coroner | Alan Wilson |
| Coroner area | Blackpool & Fylde |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Blackpool Teaching Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
,
Chief Executive,
Blackpool Teaching Hospitals NHS Foundation Trust
1
CORONER
I am Alan Wilson, senior coroner for the coroner area of Blackpool & Fylde.
2
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice
Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations
2013.
Revised Chief Coroner's Guidance No.5 Reports to Prevent Future Deaths[i] -
Courts and Tribunals Judiciary
3
INVESTIGATION and INQUEST
On 15th July 2024, I commenced an investigation into the death of Brian Kneale,
Aged 70 years. The investigation concluded at the end of the inquest on 14th
January 2025. The conclusion of the inquest was that Brian died of natural
causes.
The medical cause of his death was:
1 a Acute circulatory failure
1 b Coronary heart disease, congestive cardiomyopathy and
bronchopneumonia complicated by haemorrhagic lung infarct
4
CIRCUMSTANCES OF THE DEATH
In paragraph 3 of the Record of Inquest, I recorded as follows:
Brian Kneale was aged 70 years. Reportedly unwell for over a week with
evidence of vomiting episodes and worsening shortness of breath, he
attended hospital in Blackpool at approximately 3 pm on 27th June 2024.
After assessment, concerns were raised he had developed aspiration
pneumonia and heart failure. He was placed on the sepsis pathway but did
not receive antibiotic therapy until the early hours of the following day. He
was felt to be dehydrated and intravenous antibiotics were administered.
From the available evidence, the quantity of fluids given is unclear, although
by the afternoon of 28th June 2024 a portable chest x-ray revealed signs of
fluid overload. Given that Brian had heart failure, a kidney injury and was
showing signs of infection, the amount of fluids given probably contributed to
worsening heart failure. Reviewed by an Intensive Treatment Unit doctor, his
prognosis was felt to be poor, and Brain died at 21.45 hours on 29th June 2024
in the presence of his family. A subsequent post mortem examination
confirmed he died from the combined effects of heart failure and
bronchopneumonia.
The following is of note:
Upon assessment after arrival at hospital, concerns were raised that
Brian was in heart failure.
During the course of the investigation, his family have raised concerns
about the extent of fluids administered during his hospital admission,
which had contributed to worsening heart failure.
Having heard the available evidence, I was in agreement this was
probably the case, particularly given that Brian had shown signs of acute
kidney injury, and infection.
Bearing in mind the amount of fluids to be administered in this case
required an element of caution, the fluid balance charts had not been
recorded appropriately. They did not provide a reliable picture.
I received helpful evidence from a Consultant in Acute Medicine, who
explained that during the Autumn of 2024 he had carried out a piece of
work with the aim of improving how fluid balances are monitored and
recorded for patients in the Emergency Department, but also the Acute
Medical Unit. Notwithstanding he had not worked at the hospital since
October 2024, he felt some improvements had been made, but he
remained concerned about the position in the Emergency Department,
which remained challenging.
I was left with the impression that clinicians were at times having to
make difficult judgements in the interests of patients when they did not
have a clear picture about fluid balances.
Whether a hospital patient has been given an appropriate amount of
fluids is a vital element of a patient’s care, and when this does not
happen effectively for whatever reason, it can understandably cause
bereaved relatives significant concern.
I have a concern that although it seems the hospital Trust is aware there
is an issue regarding accurate fluid balance monitoring, the current
position is patients remain at risk if decisions may have to be made by
clinicians in the absence of accurate fluid balance charts.
This issue can also have an impact upon reviews conducted internally by
a hospital trust, and the extent to which these can be relied upon. The
authors of such reviews, in the event appropriate lessons are learned,
need to be able to form an accurate impression about the level of care
given to patients.
5
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to
concern. In my opinion there is a risk that future deaths could occur unless
action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
1. Fluid balances are not being monitored as effectively as they ought to
be;
2. In the absence of more accurate monitoring of fluid balances, clinicians
may find themselves making difficult decisions in the absence of
important information;
3. Inaccurate recording of fluid balances can leave the authors of internal
hospital reviews without the information they require to ensure the
correct lessons are learned.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR 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 22nd March 2025. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken,
setting out the timetable for action. Otherwise you must explain why no action
is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following
Interested Persons:
The Family of Mr Brian Kneale
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or
summary form. He may send a copy of this report to any person who he
believes may find it useful or of interest. You may make representations to me,
the coroner, at the time of your response, about the release or the publication
of your response by the Chief Coroner.
9
23rd January 2025 Signed:
Alan Wilson
Senior Coroner
Blackpool & Fylde
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Trust Headquarters
Blackpool Victoria Hospital
Whinney Heys Road
Blackpool
FY3 8NR
Telephone:
Email:
18th March 2025
Mr Alan Wilson
Coroner for Blackpool and Fylde
PO Box 1066
Corporation Street
Blackpool
FY1 1GB
Sent via email to:
Dear Mr Wilson
Re: Regulation 28: Report to Prevent Future Deaths – Brian Kneale
Firstly, on behalf of Blackpool Teaching Hospitals NHS Foundation Trust, I should like to offer my sincere
condolences to Mr Brian Kneale’s family.
Thank you for raising your concerns with us and please find below the Trust’s responses to the issues
raised in the report to prevent future deaths.
1. Fluid balances are not being monitored as effectively as they ought to be;
2.
3.
In the absence of more accurate monitoring of fluid balances, clinicians may find themselves
making difficult decisions in the absence of important information;
Inaccurate recording of fluid balances can leave the authors of internal hospital reviews
without the information they require to ensure the correct lessons are learned.
For context, I would like to provide you with details regarding the Trust’s ‘Fundamentals of Care’
improvement programme, which is focused on improving standards of care and patient experience.
The Fundamentals of Care Improvement Programme is divided into specific areas and each has a
nominated lead to oversee delivery and ensure actions are aligned with our vision and values.
Chairman:
Chief Executive:
RESEARCH MATTERS AND SAVES LIVES – TODAY’S RESEARCH IS TOMORROW’S CARE
Blackpool Teaching Hospitals is a Centre of Clinical and Research Excellence providing quality
up to date care. We are actively involved in undertaking research to improve treatment of our patients.
A member of the healthcare team may discuss current clinical trials with you.
These Fundamentals of Care programme areas include:
Pain Management
Acutely Unwell Patient End of Life
Acutely Unwell Patient
Improving the Fundamentals of Care
Delirium, Learning Disabilities & Dementia
Falls
Infection Prevention & Control
Medicines Management
Pressure Ulcers
Patient Experience
Nutrition and Hydration
Our fluid balance improvement work comes under our Acutely Unwell Patient Improvement Programme
and our improvement collaborative in 2023/24 focused on the deteriorating patient resulting in an
improvement of our Trust cardiac arrest rate from a mean of 1.49 to 0.68 per 1,000 admissions.
The teams focused on improving fluid balances during this time as this was noted to be the most frequent
opportunity for learning, identified during rapid evaluation of cardiac arrests for lessons learned (RECALL)
reviews. Multiple wards were involved in the Fluid Balance Improvement workstream including our Acute
Medical Unit and the Emergency Department.
The aim of this improvement workstream is to ensure that all patients have their fluid statuses monitored
appropriately by the Trust by June 2025. The drivers for this workstream include ensuring that staff are
engaged and fully trained in monitoring fluid statuses, with a standardised process for completion utilised
across the organisation, accountability for documentation, and ensuring fluid balances are communicated
across teams.
Other drivers include empowering patients to be involved in their own fluid status monitoring, by involving
patients in documenting their own fluid statuses, ensuring patients are aware of the importance of fluid
monitoring and empowering patients to challenge if a fluid balance monitoring is not completed.
The final driver for this workstream is around accurate fluid balance monitoring in patients who require it.
This involves risk stratifying fluid balance monitoring based on individual patient’s needs, ensuring there is
a minimum of 4 hourly monitoring for those who require fluid balance monitoring and ensuring outputs are
monitored and documented accurately. Also importantly, ensuring that discrepancies in fluid balances are
escalated appropriately.
Our outcomes from this improvement work to date include:
• Online fluid balance training is now mandatory on a 3-year basis – this was previously a once only
requirement.
• An updated Fluid Balance Chart has undergone multiple checks and reviews and is now ready for
adoption across the organisation in 2025.
• Risk assessing the needs for Fluid Balance has been tested with the use of Hydration Charts, an
initiative founded in Manchester. This has had positive staff and patient feedback.
3
• A fluid balance escalation process has been designed, tested and is now ready for adoption.
• This approach to fluid balance monitoring is on trial in several ward areas ensuring that fluid
balance monitoring is targeted at the sickest patients and that lower risk patients are managed via
a fluid status and hydration measurement approach.
• This combined with a mandatory dynamic daily risk assessment will ensure that every patient has
their hydration monitored and not just the sickest.
Our Next Steps:
Our next steps on our improvement journey in relation to fluid balance monitoring includes setting up a
Lead team to update the Trust’s Fluid Balance policy which will adopt the recommendations from our Quality
Improvement projects.
A Clinical Community has been launched in February 2025, with an aim to scale, spread and embed the
fluid balance work across the organisation.
A new fluid balance chart has been developed for the Trust which includes colour coding for faster
identification, an Acute Kidney Injury (AKI) staging section, a section for evidencing escalation of concerns
and balances > or < 1000mls, a section for highlighting fluid restrictions, a section on national quality
measures and a list of nephrotoxic/nephrosensitive medications to support medicines management for
patients with AKI. This will shortly be rolled out across the Trust.
The new Trust policy will also include mandatory afternoon checks and there will be a widespread
introduction which will be accompanied by a QR code for staff, to reinforce changes and expectations.
Although the Trust has had in place a Record Keeping Audit for a number of years, the methodology has
been reviewed and updated to ensure that from 1 April 2025 direct line of sight on the completion of fluid
balance charts is maintained across the organisation. This will enhance the local audits in place within the
Emergency Department such as the Care and Consistency audits which reviews fluid balance on a daily
basis.
I hope that my response has provided you with the assurance that you require that the Trust continues to
place significant improvement focus on improving standards of care for our patients and that we are making
targeted improvements to our fluid balance monitoring for all patients, through our Fluid Balance
Improvement workstream.
Should you require any further information or evidence, this can be provided.
Yours sincerely
Chief Executive
3
See every Prevention of Future Deaths report matching Blackpool Teaching Hospitals NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.