Christian Hobbs
7 Apr 2025 · Coroner David Heming · Cambridgeshire and Peterborough
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. cardiogenic shock under-recognition and delayed escalation
“patients with cardiogenic shock need defined pathways of escalation and care to improve survival.”
2. underuse of echocardiography in undifferentiated shock
“echocardiography was reported to either reduce diagnostic uncertainty or change management in 291 ( 54%) cases”
3. inadequate fluid management in shock
“Intravenous fluids were commenced but these were not targeted against response”
4. communication failures and delayed referrals
“under appreciation by some staff of how critically unwell [the deceased] was raises an issue on exchanges of information and team culture”
Linked reports
Closely relatedConfidence 0.86 · high
Earlier report
“IV fluids were not administered consistently. The longest period in which fluids were not administered was 17 hours and 45 minutes.”
This report
“Intravenous fluids were commenced but these were not targeted against response. [the deceased] remained hypotensive and tachycardic despite the fluid administration.”