Brian Kneale
PFD Report
All Responded
Ref: 2025-0043
All 1 response received
· Deadline: 20 Mar 2025
Coroner's Concerns (AI summary)
Ineffective and inaccurate monitoring of fluid balances hinders clinicians' decision-making and prevents hospital reviews from learning correct lessons.
View full coroner's concerns
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.
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.
Responses
Action Planned
The Trust will update its Fluid Balance policy, roll out a new fluid balance chart with colour coding and other improvements, introduce mandatory afternoon checks, and update its Record Keeping Audit methodology to maintain direct oversight of fluid balance chart completion. (AI summary)
The Trust will update its Fluid Balance policy, roll out a new fluid balance chart with colour coding and other improvements, introduce mandatory afternoon checks, and update its Record Keeping Audit methodology to maintain direct oversight of fluid balance chart completion. (AI summary)
View full response
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. 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.
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.
3
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.
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. 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.
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.
3
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.
Sent To
- Blackpool Teaching Hospitals NHS Foundation Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
20 Mar 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
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
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
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.
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.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Healthcare trust risk information visibility
Southport Inquiry
Inaccurate and inaccessible patient records
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.