_ 1_ Jones was a frail elderly lady who was moved from the MRI to Trafford General post-operatively for rehabilitation under the Trust structure: It was a planned transfer: However due to limited transport availability she arrived at Trafford General out of hours after waiting for transfer: As a result she was clerked in and risk assessed out of hours despite the recognised risks of moving frail elderly patients out of hours_ The inquest was told that this is not uncommon as transfers such as these are made via ambulance and are low priority and moved where needed; The falls risk assessment was completed outside the Trust target time primarily as a result of the late arrival; The documentation within the nursing notes, particularly the fluid charts was poor quality, making it difficult to understand what had happened in relation to the hydration of Mrs Jones; The documentation issue was exacerbated by the Trust IT merger having resulted in the loss of a number of documents. It was unclear how the Trust were managing the risks around lost medical records where the IT merger was at the root of the issue;
5. Despite her frailty there was no evidence available at the inquest of a referral to a dieticianlnutritionist: There was to have been a referral to SALT in February but no trace could be found of the referral; 6, There was no evidence of clear clinical review of the outcome of the fluid charts