Concerns raised 22 Failure of child death review to identify learning across relevant environmental and service factors View source Uncertainty about learning identified through paediatric mortality review View source Lack of funding mechanisms enabling cardiac screening for competitive boxers View source Failure to obtain echocardiography for critically unwell patients in shock View source Failure to target intravenous fluid management against patient response View source Failure to retain emergency department monitor data for retrospective analysis View source Failure to undertake deep-dive safety audits examining patterns and trends View source Delays in obtaining the first blood gas View source Deficiencies in ECG interpretation View source Failure to formulate a differential diagnosis View source Lack of parental awareness of sudden cardiac death red-flag symptoms View source Insufficient radiologist capacity for expanding imaging demand View source Failure of communication within and between clinical teams View source Insufficient clinical knowledge of medication effects and pharmacologic consequences View source Lack of funding and implementation of defined cardiogenic shock escalation and care pathways View source Failure to embed HSSIB critically unwell patient guidance in staff training View source Lack of recorded assessment of radiological images View source Lack of recorded evidence on key aspects of patient care View source Insufficient critical care training View source Insufficient critical care resources View source Insufficient audit of sepsis pathway use View source Insufficient sepsis pathway training View source See 19 more concerns
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AI-generated summary
Christian James Gabriel Hobbs · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christian James Gabriel Hobbs, a 17-year-old, suffered an acute deterioration at home and was taken to hospital on 26 December 2017, where he developed cardiac arrest and died after treatment was stopped. The inquest recorded multi-organ failure, cardiogenic shock and arrhythmogenic cardiomyopathy. Concerns included the absence of an echocardiogram before his arrest, non-targeted fluid management, delays in obtaining blood gases, team communication, radiology documentation, differential diagnosis, ECG interpretation, record keeping and emergency-department alarm data retention.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure of child death review to identify learning across relevant environmental and service factors
Wider context from the report “POINT R – CHILD DEATH OVERVIEW PANEL REVIEW
Whilst the death occurred in Cambridgeshire, it is understood that the Northamptonshire CDOP reviewed this matter. However, it appears that a copy of the Analysis Proforma is not available but taking information from a collation of reviews, there was no identification of any learning in terms of factors intrinsic to the social environment, physical environment or service provision .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about learning identified through paediatric mortality review
Wider context from the report “POINT S – NWAFT PAEDIATRIC MORTALITY REVIEW
It is unclear whether any NWAFT paediatric review found any issues from a learning perspective given the matters analysed at length within the coronial investigation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Lack of funding mechanisms enabling cardiac screening for competitive boxers
Wider context from the report “POINT Q – TESTING IN COMPETITIVE SPORTS FOR CARDIAC CONDITIONS
I have a concern about funding mechanisms being available to say England Boxing that would enable appropriate screening for competitive boxers where there is already a mandatory need for a medical examination under the ‘fit or not fit to box’ protocol. This would aid further research on this important topic.
Additionally, there may be a lack of general awareness for parents of sports participants on the issue of sudden cardiac death and so there may be a gap in knowledge/understanding of possible emergence of red flag symptoms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain echocardiography for critically unwell patients in shock
Wider context from the report “POINT B - RE: ECHOCARDIOGRAPHY
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to target intravenous fluid management against patient response
Wider context from the report “POINT C - FLUID MANAGEMENT
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to retain emergency department monitor data for retrospective analysis
Wider context from the report “POINT N - DATA FROM EMERGENCY DEPARTMENT ALARMS
The monitor evidence was not available for analysis of heart rhythms etc because there was no retention of the data at the time . This hampered consideration of data in the death that required detailed review and this is a concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake deep-dive safety audits examining patterns and trends
Wider context from the report “POINT P - PATIENT SAFETY IN SOME TRUST AREAS
This is a concern and it is unclear as to whether there has been a deep dive audit/review to look at patterns/trends rather than simply looking at raw overall mortality data .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining the first blood gas
Wider context from the report “POINT G – BLOOD GASES/ ELEVATED LACTATE
There was a delay in getting the first blood gas . A cannula was in situ by circa 19:00, when intravenous fluids and antibiotics were given. A venous blood gas should have been taken from this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in ECG interpretation
Wider context from the report “POINT L – ECG ANALYSIS
Some Issues emerged in evidence on the interpretation of the ECG at 18:10.
This again raises concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to formulate a differential diagnosis
Wider context from the report “POINT I - DIFFERENTIAL DIAGNOSIS
A recurring theme is lack of a differential diagnosis which raises concerns about training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Lack of parental awareness of sudden cardiac death red-flag symptoms
Wider context from the report “POINT Q – TESTING IN COMPETITIVE SPORTS FOR CARDIAC CONDITIONS
I have a concern about funding mechanisms being available to say England Boxing that would enable appropriate screening for competitive boxers where there is already a mandatory need for a medical examination under the ‘fit or not fit to box’ protocol. This would aid further research on this important topic.
Additionally, there may be a lack of general awareness for parents of sports participants on the issue of sudden cardiac death and so there may be a gap in knowledge/understanding of possible emergence of red flag symptoms .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Insufficient radiologist capacity for expanding imaging demand
Wider context from the report “POINT F - RADIOLOGY NATIONALLY
I have a concern over whether there are sufficient numbers of radiologists to cover the ever-increasing expansion of imaging as a key diagnostic tool.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure of communication within and between clinical teams
Wider context from the report “POINT D - TEAM INTERACTIONS
A concern arises over communications within a team itself and also interactions with other teams – e.g. when a referral is made to the medical team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinical knowledge of medication effects and pharmacologic consequences
Wider context from the report “POINT K- ANTIEMETIC MEDICATION
I have a concern on clinical knowledge of such effects of this drug and pharmacologic consequences of other drugs also .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Lack of funding and implementation of defined cardiogenic shock escalation and care pathways
Wider context from the report “POINT A - RE: CARDIOGENIC SHOCK CS)
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to embed HSSIB critically unwell patient guidance in staff training
Wider context from the report “POINT O – LEARNING FROM HSSIB REPORTS
I have a concern on whether the HSSIB report – RECOGNISING AND RESPONDING TO CRITICALLY UNWELL PATIENTS is firmly embedded in staff training .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Lack of recorded assessment of radiological images
Wider context from the report “POINT E – RADIOLOGY WITHIN NWAFT
Another recurring theme is radiology within the trust. In the case of Christian, nothing is recorded in the notes on assessment of the X-Rays undertaken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Lack of recorded evidence on key aspects of patient care
Wider context from the report “POINT M -RECORD KEEPING
There was a lack of recorded evidence on key aspects of Christians care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Insufficient critical care training
Wider context from the report “POINT H - CRITICAL CARE
There are concerns about resources and training within the trust for this specialty .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Insufficient critical care resources
Wider context from the report “POINT H - CRITICAL CARE
There are concerns about resources and training within the trust for this specialty .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Insufficient audit of sepsis pathway use
Wider context from the report “POINT J - SEPSIS PATHWAY
This is again another theme and accordingly raises a concern about training and auditing .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Safeguarding Children Partnership; that does not assign responsibility.
PFD Monitor interpretation Insufficient sepsis pathway training
Wider context from the report “POINT J - SEPSIS PATHWAY
This is again another theme and accordingly raises a concern about training and auditing .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a joint decision process to determine when child deaths should be brought to CDOP, informed by completed investigations and inquests.
Verbatim wording from the response “• The CDR team reached a joint decision on when to bring a case to CDOP. Typically, children and young people's deaths are not usually discussed until formal processes, such as serious incident (SI) investigations or inquests, have concluded. Delaying the CDOP panel ensures that the SI investigation reports, and inquest conclusions inform the CDOP discussion. When the CDR team knows that inquests will be delayed, they decide whether to have an initial discussion at CDOP to identify learning. If so, the case will be returned to CDOP for further discussion and ratification.” Source location Response from Northamptonshire Children Safeguarding Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review serious incident and comparable investigation reports to identify service-related modifiable factors and challenge insufficient findings or improvement actions.
Verbatim wording from the response “• The CDR team review SI reports and those from similar investigative processes. If they have concerns that the report findings don't reflect the issues associated with the child's death and/or the improvement actions don't sufficiently address the issues identified, the CDR team will seek further information from the organisation. If the team still has concerns, they elevate them through the ICB quality team. When reviewing the deaths of children where there has been an SI investigation, CDOP will identify modifiable factors related to the service provision, which echo those found in the investigation and others CDOP believe to be important. This mirrors practice in other CDOPs I've chaired.” Source location Response from Northamptonshire Children Safeguarding Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Collect, collate and store all child death review forms and associated communications in accordance with data protection requirements.
Verbatim wording from the response “• All CDOP forms and associated communication are now collected, collated and stored appropriately per the General Data Protection Regulation. Ensuring all relevant information is available supports a comprehensive review of the deaths of children and young people in” Source location Response from Northamptonshire Children Safeguarding Partnership
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations