Recurring concern

Failure to reliably recognise and respond to dehydration

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First reported 17 Dec 2020•Latest report 7 Jan 2026

Definition

What this concern includes

Includes failures in controls specifically dedicated to recognising, assessing, responding to or escalating dehydration risk, including care-staff competence, clinical assessment methods, misleading reassurance, safeguarding assessment and timely referral or treatment across care and healthcare settings.

Not included

Excludes general nutrition, hydration provision or fluid-balance monitoring failures where dehydration recognition or response is not the material unsafe condition.
Excludes generic staff training, staffing, communication or documentation deficiencies unless they directly impair recognition or response to dehydration.
Excludes treatment or follow-up failures after dehydration has been reliably recognised and appropriately escalated, unless the response process itself remains deficient.
Excludes other causes of clinical deterioration or unrelated conditions where dehydration is not the identified hazard.

Reports: 2
Individual concerns: 4
Date range: 2020–2026
Stated actions: 3

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission1

Department of Health and Social Care1

Health Centre1

NHS England1

NHS Greater Manchester Integrated Care Board1

Walsall Borough Council1

Walsall Healthcare NHS Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

7 Jan2026
Black Country
Concerns raised1
1. Use of insensitive Capillary Refill Time testing for dehydration assessment
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Educate clinicians to assess dehydration in children, recognise early signs, and use appropriate clinical indicators.
  Stated by Walsall Safeguarding Partnership OrganisationsStatus unclear
2. Action
  Deliver training on identifying dehydration in children, including assessing fluid intake and output, weight, and other relevant indicators.
  Stated by Birchills Health CentreStated completed
3. Action
  Discuss autism, ARFID, and other risk groups to support increased suspicion of dehydration and earlier secondary-care assessment despite normal clinical findings.
  Stated by Birchills Health CentreStated completed
Respondent positions 3
1. Position
  CRT is moderately effective and useful as one sign, but should not be used alone to assess dehydration.
  Stated by NHS EnglandDisputes the concern
1. Position
  Assessment of dehydration is a basic professional competency, so NHS England does not publish dedicated guidance on it.
  Stated by NHS EnglandOutside remit
2. Position
  Further national dehydration guidance is unlikely to increase recognition because clinicians are taught to use multiple assessment indicators.
  Stated by NHS EnglandNo action considered necessary
AI-generated summary

Joshua Lee Allcock · 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

Joshua Lee Allcock, a five-year-old boy with complex medical needs and a limited diet, developed severe dehydration after entering foster care and died on 3 January 2023 despite hospital treatment. Concerns included the lack of a formal autism diagnosis and related dietary support, variation in autism assessment practice, and the potential for the capillary refill time test to provide misleading reassurance when assessing dehydration in children with similar circumstances.

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.
PFD Monitor interpretation
Use of insensitive Capillary Refill Time testing for dehydration assessment
Wider context from the report
“5. The expert evidence also indicated that the Capillary Refill Time (CRT) test used to assess dehydration by checking peripheral blood flow is a very insensitive test and can provide misleading reassurance. Therefore, my concern is that young children with similar circumstances to Joshua maybe at risk when assessing levels of dehydration. NHS England may wish to consider reviewing their guidance for health professionals. ”
Source location
Joshua Lee Allcock · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
Educate clinicians to assess dehydration in children, recognise early signs, and use appropriate clinical indicators.

Verbatim wording from the response
“• Education for clinicians regarding assessment of dehydration in children, including recognition of early signs and use of appropriate clinical indicators.”

Source location
2026-0012 - Response from Birmingham and Solihull Integrated Care Board
Page 2 · response
Published 20 January 2026
Open published response
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
Deliver training on identifying dehydration in children, including assessing fluid intake and output, weight, and other relevant indicators.

Verbatim wording from the response
“2. Your report highlighted the insensitivity of CRP as a way to identify dehydration. We have had a presentation on identification of dehydration in children to help remind clinicians on most effective ways of assessing hydration status. The presentation highlighted that a clear record of fluid intake and output is required as well as considering recording weight as a more accurate clinical indicator to help identify dehydration- useful if there are other readings to compare to. Other things to consider include a urine dipstick if possible. This child was reviewed at the local accident and emergency department on 25.12.22. The discharge summary had no information about the clinical assessment of this child.”

Source location
2026-0012 - Response from Birchills Health Centre
Page 1 · response
Published 20 January 2026
Open published response
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
Discuss autism, ARFID, and other risk groups to support increased suspicion of dehydration and earlier secondary-care assessment despite normal clinical findings.

Verbatim wording from the response
“3. We have discussed the links between autism and ARFID. In addition, we have also discussed ARFID in other risk groups. If there is a suspicion or a formal diagnosis of neurodevelopmental disorders and ARFID, we discussed the need for lower suspicion of dehydration in these cases despite normal clinical findings and having a lower threshold for secondary care assessment.”

Source location
2026-0012 - Response from Birchills Health Centre
Page 1 · response
Published 20 January 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
CRT is moderately effective and useful as one sign, but should not be used alone to assess dehydration.

Verbatim wording from the response
“Capillary Refill Time (CRT) is a moderately effective but imperfect clinical sign for diagnosing dehydration in a child. A prolonged CRT (>2 seconds) is a strong indicator of dehydration, but its sensitivity is variable, so a normal CRT does not reliably exclude dehydration. It is one of the most useful individual signs, but a combination of signs (such as skin turgor, respiratory pattern, and capillary refill considered together) is more accurate than any single sign alone.”

Source location
2026-0012 - Response from NHS England
Page 3 · response
Published 20 January 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Assessment of dehydration is a basic professional competency, so NHS England does not publish dedicated guidance on it.

Verbatim wording from the response
“Assessment of dehydration is on the curriculum of undergraduate and relevant postgraduate medical courses and the emphasis is not on reliance on a single indicator. NHS England does not publish guidance on the assessment of dehydration as it is in the basic domain of medical professionals to know this. Publication of further guidance is unlikely to result in increased recognition. However, I note that your Report has been addressed to other health organisations, including Walsall Healthcare NHS Trust and Birchill’s Medical Centre. They may be able to provide further information around the local guidance on assessing dehydration and the use of CRT tests.”

Source location
2026-0012 - Response from NHS England
Page 3 · response
Published 20 January 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Further national dehydration guidance is unlikely to increase recognition because clinicians are taught to use multiple assessment indicators.

Verbatim wording from the response
“Capillary Refill Time (CRT) is a moderately effective but imperfect clinical sign for diagnosing dehydration in a child. A prolonged CRT (>2 seconds) is a strong indicator of dehydration, but its sensitivity is variable, so a normal CRT does not reliably exclude dehydration. It is one of the most useful individual signs, but a combination of signs (such as skin turgor, respiratory pattern, and capillary refill considered together) is more accurate than any single sign alone.”

Source location
2026-0012 - Response from NHS England
Page 3 · response
Published 20 January 2026
Open published response
17 Dec2020
Manchester South
Concerns raised3
1. Failure to recognise dehydration risk
2. Limited care-home staff ability to recognise and respond to escalating dehydration risk
3. Lack of national guidance for care-home staff on recognising, responding to and escalating dehydration risk
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 4
1. Position
  Existing website information and links to authoritative guidance provide providers with the information needed to support service users’ hydration needs.
  Stated by Care Quality CommissionExisting arrangements considered sufficient
1. Position
  The review found insufficient evidence of regulatory breaches, with appropriate nutrition and hydration care plans, monitoring records and assessments in place.
  Stated by Care Quality CommissionDisputes the concern
2. Position
  Further national dehydration guidance is not considered necessary because appropriate guidance and best-practice materials already exist.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
3. Position
  Publishing detailed standards for specific conditions falls outside the regulator’s remit because authoritative expert organisations provide that guidance.
  Stated by Care Quality CommissionOutside remit
AI-generated summary

Philip Taylor · 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

Philip Taylor, who had Lewy Body Dementia and lived in a residential care home, became severely dehydrated during a chest infection and died in hospital on 6 January 2020 after developing an acute kidney injury. Concerns included failure to recognise and respond to dehydration, delayed ambulance transfer and hospital assessment, inadequate monitoring, and limited national guidance for care home staff and paramedics.

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.
PFD Monitor interpretation
Failure to recognise dehydration risk
Wider context from the report
“1. Mr Taylor was seen by a GP the day before he died. His risk of dehydration was not recognised. The precise observations of the GP were difficult to ascertain at the inquest for a number of reasons. • The inquest was told that the GP had been called as the care home had concerns about Mr Taylor. However, the GP did not ascertain his temperature because the inquest was told that he did not routinely carry or use a thermometer when he saw patients in a care home. The explanation provided to the inquest was that as a GP he did was not equipped with medical gadgets in the way for example NWAS staff were. • The notes relating to the visit had not been written up until the next day and the GP could not recall all of any observations. It was unclear why that had occurred. ”
Source location
Philip Taylor · Prevention of Future Deaths report
Page 2 · 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.
PFD Monitor interpretation
Limited care-home staff ability to recognise and respond to escalating dehydration risk
Wider context from the report
“3. The staff in the care home were not medically qualified. The inquest heard that their ability to recognise and respond to an escalating risk of dehydration was limited. There was no national guidance to assist care home staff in understanding how to recognise; respond and escalate the risk of dehydration. ”
Source location
Philip Taylor · Prevention of Future Deaths report
Page 2 · 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.
PFD Monitor interpretation
Lack of national guidance for care-home staff on recognising, responding to and escalating dehydration risk
Wider context from the report
“3. The staff in the care home were not medically qualified. The inquest heard that their ability to recognise and respond to an escalating risk of dehydration was limited. There was no national guidance to assist care home staff in understanding how to recognise; respond and escalate the risk of dehydration. ”
Source location
Philip Taylor · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing website information and links to authoritative guidance provide providers with the information needed to support service users’ hydration needs.

Verbatim wording from the response
“Information on the CQC website to signpost providers on meeting Regulation 14 is available. This includes links to a variety of best practice guidance including Diet, nutrition and obesity (National Institute for Health and Care Excellence) which is deemed relevant to all service providers. Other specific guidance to adult social care service included links to BAPEN (British Association for Parenteral & Enteral Nutrition): BAPEN: Malnutrition universal screening tool; Malnutrition Universal Screening Tool (MUST) explanatory booklet; Nutrition for specific groups (Royal College of Nursing); Nutrition support in adults (National Institute for Health and Care Excellence); Nutrition support in adults (NICE); Nutritional care and older people (Social Care Institute for Excellence, March 2009).”

Source location
2020-0289-Response-from-CQC-Redacted
Page 3 · response
Published 7 January 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The review found insufficient evidence of regulatory breaches, with appropriate nutrition and hydration care plans, monitoring records and assessments in place.

Verbatim wording from the response
“The death of Mr Taylor was reviewed as part of our regulatory duties, to assess whether there was any evidence of failings by a Registered Person that amounted to a breach of the Regulations. The conclusion of the initial review found that there was insufficient evidence of a breach of the Regulations. Mr Taylor had a nutrition and hydration care plan in place, along with a variety of other appropriate and relevant care plans. These were being reviewed on a monthly basis. An assessment of Mr Taylor’s nutrition needs had also been recently reviewed in December 2019. Daily records were being completed and included food and fluid charts. The latter records both food offered and fluid taken by Mr Taylor, which would have assisted with auditing to ensure appropriate fluid levels were maintained. The meal chart is a similar mechanism for ensuring appropriate food intake.”

Source location
2020-0289-Response-from-CQC-Redacted
Page 4 · response
Published 7 January 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Further national dehydration guidance is not considered necessary because appropriate guidance and best-practice materials already exist.

Verbatim wording from the response
“In relation to the national guidance that is available to care home staff on recognising and responding to the risk of dehydration, I am advised that in its response to you, the CQC has provided a detailed explanation of the guidance and best practice materials that are available. I will not repeat the detail here. However, you may wish to note that Departmental officials have made enquiries with NICE, which has confirmed that appropriate guidance is available, issued by NICE itself and others.”

Source location
2020-0289-Response-from-Dept.-of-Health-and-Social-Care-Redacted
Page 2 · response
Published 7 January 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Publishing detailed standards for specific conditions falls outside the regulator’s remit because authoritative expert organisations provide that guidance.

Verbatim wording from the response
“CQC does not publish detailed standards and expectations about specific conditions. To do so would duplicate the work of more appropriate expert sources (for example NICE and SCIE - see below). We expect Registered Persons to keep up to date with, take on board and implement good practice standards provided by relevant authoritative organisations.”

Source location
2020-0289-Response-from-CQC-Redacted
Page 3 · response
Published 7 January 2021
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Use of insensitive Capillary Refill Time testing for dehydration assessment

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised3

Failure to recognise dehydration risk

Limited care-home staff ability to recognise and respond to escalating dehydration risk

Lack of national guidance for care-home staff on recognising, responding to and escalating dehydration risk

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Actions described in response 3

Respondent positions 3

Respondent positions 4