Recurance · prevention of future deaths reports
Pre-inquest brief
Inconsistent iv fluid administration and inadequate shock management
The earlier warning
George Kearsey · 9 Feb 2023 · Graeme Irvine, East London
“IV fluids were not administered consistently. The longest period in which fluids were not administered was 17 hours and 45 minutes.”
judiciary.uk/…/george-kearsey-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to George Kearsey (9 Feb 2023) · stated timescale: March, April and May 2023
“Audits have been completed in Geriatrics and Frailty wards and the findings were presented at the monthly Clinical Group Quality & Safety meeting and the Quality Governance Steering Group. Across the 9 audited areas, over the period of three months (March, April and May 2023), the audits demonstrated that 87% of patients' fluid charts were completed, recorded on vital pac and available to review. Each patient that did not have fluid chart completed and recorded on vital pac (due to a new admission”
judiciary.uk/…/2023-0050-Response-from-Department-of-Health-and…
What recurred
- 7 Apr 2025 · Christian Hobbs · David Heming · Closely related · confidence 0.86 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.