Blackpool Teaching Hospitals NHS Foundation Trust
NHS / Health Body
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)
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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.