“IV fluids were not administered consistently ”
Dated 9 Feb 2023, from the coroner for East London. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 6 Apr 2023.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated9 Feb 2023
- Deadline6 Apr 2023
- Published on judiciary.uk24 Feb 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Barking, Havering and Redbridge University Hospitals NHS TrustNamed in the report as “Barking, Havering & Redbridge NHS Trust” | Response publishedPublished on judiciary.uk in February 2023. |
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in February 2023. |
The coroner’s concerns
1. IV fluids were not administered consistently . The longest period in which fluids were not administered was 17 hours and 45 minutes. 2. Contrary to Trust pol icy , fluid ba lance charts were not put in place to assess Mr Kearsey's fluid intake and output. 3. C li nical records were poorly maintained , resulting in an unclear picture of flu id administration . 4. 6 Consultant-led ward rounds did not adequately review fluid mon itoring.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2023-0050
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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
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