There was a need to:

• Get support much earlier – ideally the initial review that was taken by the junior doctor should have included the registrar and an early AITU review.
• Have regular hourly reviews by senior medical staff
• Undertake arterial line – continuous blood pressure monitoring and CVP assessment earlier.
• Catheterise earlier
• Review the EWS trend
• Discuss 's potential prognosis and the need to identify how far treatment and/or care should proceed in relation to a possible 'Do Not Resuscitate' order.