“ARE: POINT A - RE: CARDIOGENIC SHOCK CS) TO: i”

The coroner’s concerns

ARE: POINT A - RE: CARDIOGENIC SHOCK CS) TO: i. Department of Health and Social Care Regulation 28 – After Inquest Document Template Updated 30/07/2021 ii. iii. Cambridgeshire and Peterborough ICB NWAFT I have a concern over funding availability and implementation of the key recommendations set out below. The Intensive Care Society and British Cardiovascular Society issued a comprehensive report in October 2022 with the title - Shock to Survival: a framework to improve the care and outcomes of people with cardiogenic shock in the UK. The Executive Summary reported that patients with cardiogenic shock need defined pathways of escalation and care to improve survival. It was stated that CS is a commonly encountered but often under recognised clinical challenge with high mortality. This document outlined several recommendations as part of a systems approach to improving patient survival and experience. These included but were not limited to: A. Increase awareness among healthcare staff that any deteriorating patient with an elevated National Early Warning Score (NEWS) 2 and evidence of hypoperfusion should prompt consideration of CS as a potential cause. Echocardiography or focused cardiac ultrasound FoCUS and electrocardiogram should follow urgently. B. Improve access to echocardiography out of hours (including FoCUS with expert review) to support/exclude the diagnosis of CS or other cardiac pathologies C. Adopt SCAI staging as the standardised descriptor of CS to facilitate triage, communication and expediency of discussion with a CS centre. D. Establish CS centres as part of regional CS networks to bring together the most critically ill patients with the right clinical expertise E. Ensure equity of access to CS expertise and care, including short-term MCS, through the design of CS networks and distribution of CS centres F. Develop clear pathways of care and protocols for CSS care within networks to complement existing acute cardiac care pathways, including 24/7 access to CS MDT's and transfer to CS centres G. Developed network protocols for patient selection for short- term MCS H. Define a minimum CS data set and collect this data, including through existing national audits, encompassing the entire patient pathway Regulation 28 – After Inquest Document Template Updated 30/07/2021 I. Prioritise high-quality research in CS to address important areas of uncertainty, including a patient selection for short-term MCS and costeffectiveness of improved care pathways. The report recognised that the National Cardiac Pathway Improvement Programme (CPIP) represented an opportunity to embed many of these recommendations, to potentially transform outcomes in CS patients, and CPIP leaders nationally and regionally should work with stakeholders and CS experts to implement them. POINT B - RE: ECHOCARDIOGRAPHY TO: i. ii. iii. iv. v. Department of Health and Social Care Royal College of Emergency Medicine The Faculty of Intensive Care Medicine NWAFT Cambridgeshire and Peterborough ICB Christian had not had an echocardiogram prior to his arrest. This was a concerning feature of his care in the ED given he was critically unwell and in a shocked state. Whilst the paper below focussed on critical care, there is a concern on the use of echocardiography in EDs and also within critical care departments given the findings that emerged from this research. The paper by Luke Flower (et al) : The use of echocardiography in the management of shock in critical care: a prospective, multi-centre, observational study ( Intensive Care Medicine :2024) emphasised that echocardiography was reported to either reduce diagnostic uncertainty or change management in 291 ( 54%) cases, with a change in management in 270 (50%) and a reduction in of diagnostic uncertainty in in 120 ( 20%) of patients. The conclusion was that urgent echocardiography is not routinely used in the assessment of critically ill patients with shock in the UK and Crown Dependencies, despite international guidance. The study suggests that echocardiography may alter management and improve diagnostic certainty in patients with undifferentiated shock. Future work should explore barriers to the expansion of echocardiography provision within critical care to permit improved equity of care amongst patients presenting with shock. The study was on behalf of NEAT ECHO collaborators and in association with the British Society of Echocardiography (BSE). The BSE highlighted an additional study finding that it was disappointing to read that only 25% of echocardiograms adhered to national storage guidance. This discrepancy was said in part to relate to poor underlying infrastructure for electronic image storage and transfer. The BSE commented that this was a reminder that delivering a high-quality echo service is not Regulation 28 – After Inquest Document Template Updated 30/07/2021 only reliant on having an echo machine, but also a variety of additional background information technology components that the BSE would recommend as inconceivable to be absent from a modern CT or MRI imaging service. POINT C - FLUID MANAGEMENT To: i. ii. NWAFT Cambridgeshire and Peterborough ICB (CPICB) Intravenous fluids were commenced but these were not targeted against response. Christian remained hypotensive and tachycardic despite the fluid administration. This is an area of concern also. Another example of this is seen in a coronial investigation into the death of LM within the trust under reference 01976-2023. An independent expert flagged an issue on fluid management in that matter and the Trust SI report also found that the effects of Hartman’s solution was not evaluated, and no further fluids were given. Additionally, adherence to policy on completion of fluid balance charts and the understanding and need for acting on flags is a matter of concern. It is not clear if the trust and CPICB has identified this as a recurring theme in audits/deep dive reviews. POINT D -TEAM INTERA

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

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judiciary.uk, Prevention of Future Deaths reports, 2025-0176

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0