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1) There were incomplete records kept and especially in respect of the fluid balance chart thereby rendering it an ineffective diagnostic tool.
2) That a patient was placed in the care of Nurse who neither understood the NEWS scoring system, did not apply it correctly and failed t0 escalate patient's condition in circumstances where she ought to have done s0.
3)That the Trust did not have in place a sufficiently rigorous or effective system for testing and monitoring the training, knowledge, understanding and compliance of agency staff. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; namely by the 18th of January 2017 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. such

COPIES and PUBLICATION mave sent & copy ofmyrarorttotha Chief Coroner and t the following Interested Persons amaleo under a duty to gond the Chief Coroner & copy of your rsponse_ The Chief Coroner may publish elther or both in a complete or redacted Or Bummary form; He may send & Copy Of this report to any person who he believes may find it useful or of Interest You may make representatlons t0 me; the coroner, at the time of your response, about the release or the publication of your response by the Chlef Coroner Kate Thomas Assletant Coroner Mld Kont and Medway 21* November 206