David Fenn
27 Feb 2026 · Coroner Lincoln Brookes · Essex
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. sepsis not recognised and Sepsis 6 pathway not followed
“Signs of sepsis where not appropriately recognised and the Sepsis 6 Pathway was not followed”
2. lack of early consultant review
“An early Consultant [name redacted] was not sought”
3. communication breakdown due to poor mobile signal
“The later attempt to seek the Consultant's views was hampered by the use of a mobile phone which had poor signal in the operating theatre and crucial information was not fully imparted/understood”
4. junior doctor reluctance to challenge consultant
“The junior doctor did not feel able to challenge the view of the Consultant to discharge nor did they seek to reapproach them with fuller information”
5. failure to obtain alternative consultant opinion
“An alternative Consultant's opinion was not sought”
6. missed multidisciplinary team discussion
“The Multi Disciplinary Team meeting the following morning did not discuss Mr [name redacted] case when it should have”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“The nurse did not feel confident enough to challenge the prescription (as she perceived it) effectively or escalate / refer to another doctor.”
This report
“The junior doctor did not feel able to challenge the view of the Consultant to discharge nor did they seek to reapproach them with fuller information.”