Inconsistent iv fluid administration and inadequate shock management

Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals. ?Every quote shown was checked by code to appear word for word in the original report.

• 2023 → 2025Christian Hobbs2 years 2 months after George Kearsey · different coronerClosely relatedConfidence 0.86 · high

  Closely relatedConfidence 0.86 · high

  Both reports highlight problems with intravenous fluid management in the trust, specifically failures to administer or monitor fluids appropriately.

  George Kearsey · 9 Feb 2023

  “IV fluids were not administered consistently. The longest period in which fluids were not administered was 17 hours and 45 minutes.”

  Check it in the source

  Christian Hobbs · 7 Apr 2025

  “Intravenous fluids were commenced but these were not targeted against response. [the deceased] remained hypotensive and tachycardic despite the fluid administration.”

  Check it in the source

  Stated action in the response to the earlier report

  “Cross site audits have been completed on COTE (Care of the Elderly) wards on a random basis to understand a cross section of compliance with fluid management with no notice given to the ward in advance of the audit. The audits capture patients who are on fluid restriction, patients requiring oral and intravenous hydration, parenteral nutrition and output monitoring, whether the intake and output is entered on Careflow Vitals and appropriate action taken as necessary. The audits were completed by”

  Earlier report in the app · Later report in the app