“(brief summary of matters of concern) Jean was known to have significant cardiovascular…”

The coroner’s concerns

(brief summary of matters of concern) Jean was known to have significant cardiovascular problems and from her admission there were signs this was worsening. Her blood pressure was low, which would normally be treated with intravenous fluids, but excess fluids would put more pressure on her heart, and thus she was also treated with a low dose of furosemide. The management of Jean’s fluid balance was important for the following reasons; she had heart failure, she had chronic renal failure, she had signs of a superimposing acute kidney injury and she was scoring on the NEWS chart from admission, such that the algorithm required the fluid balance to be monitored. Jean had signs of sepsis. Regulation 28 – After Inquest Document Template Updated 30/07/2021 6 7 8 I find at inquest that Jean’s fluid balance was not monitored, which I determined to be a failure in care. It was not monitored by the nursing or the medical staff. Whilst I could not find that knowledge of Jean’s fluid balance would have altered the outcome, it is a matter of grave concern that this basic nursing care was ignored, and these important clinical indicators not monitored by the medical staff.

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, 2025-0059

Added to Minute Book

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