A number of issues were raised by members of staff and others about the care at the Royal Bolton Hospital as foilows was told that despite one-to-one nursing being required for Mr Wilkinson and indeed being ordered, this is not always available. There was clear evidence that had such nursing standards been available Mr Wilkinson may not have developed the problems which led to his death (2) Members of staff reported that they sometimes find it difficult if not impossible to log onto the computer system in the hospital and theretore cannot record matters as they should be recorded. This is apparently due to the inadequacies of the system rather than the inabilities of the individuals.

(3) A Fluid Balance Chart was ordered to be kept and it was accepted that this was not done and an incomplete Fluid Balance Chart resulted.

(4) It was agreed that there was no direct orthopaedic input available at the Emergency Department at the hospital and that it would be sensible for this to have been available_ Had this been available Mr Wilkinson would probably not have been admitted to the hospital in the first place with a fractured ankle and therefore would not_presumably_have developed clostridium difficile leading_to his death He was described as an unnecessary in-patient