Recurring concern

Unreliable recognition, monitoring and management of electrolyte abnormalities

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First reported 25 Jul 2014•Latest report 14 Nov 2024

Definition

What this concern includes

Includes failures of controls specifically dedicated to recognising, assessing, investigating, monitoring or managing electrolyte abnormalities, including established clinical systems, relevant policies, testing before or during treatment, review of results and appropriate response across primary and secondary care.

Not included

Excludes deficiencies concerning a single named electrolyte disorder, such as hyponatraemia, when no broader electrolyte-abnormality process is identified.
Excludes generic clinical training, documentation, staffing or governance deficiencies unless they are directly tied to the electrolyte-abnormality recognition, monitoring or management process.
Excludes failures in prescribing or administering treatment where no electrolyte-abnormality monitoring or management control is implicated.
Excludes unrelated laboratory, diagnostic or clinical-monitoring processes that do not concern electrolyte abnormalities.

Reports: 2
Individual concerns: 3
Date range: 2014–2024
Stated actions: 5

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.

NHS Surrey and Sussex Integrated Care Board1

Royal College of Pathologists1

Royal College of Physicians1

Royal College of Psychiatrists1

Surrey and Borders Partnership NHS Foundation Trust1

Woodlands Surgery1

Worcestershire Acute Hospitals 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.

14 Nov2024
Worcestershire
Concerns raised2
1. Failure to ensure doctors are aware of and comply with electrolyte-monitoring policies
2. Failure to ensure doctors understand the importance of U&E monitoring before prescribing intravenous fluids
This report raised 1 other concern. 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 4
1. Action
  Issue an advisory notice reminding doctors to follow NICE guidance when prescribing intravenous fluids and monitoring electrolytes.
  Stated by Worcestershire Acute Hospitals NHS TrustStated completed
2. Action
  Operate a working party to examine non-compliance with fluid-monitoring standards and address identified knowledge or skills gaps.
  Stated by Worcestershire Acute Hospitals NHS TrustStated in progress
3. Action
  Improve the intranet’s policy visibility and search function so electrolyte-correction policies are readily available.
  Stated by Worcestershire Acute Hospitals NHS TrustStated completed
1. Action
  Require all Trust doctors to undertake continuing professional development on electrolyte balance.
  Stated by Worcestershire Acute Hospitals NHS TrustStated planned
AI-generated summary

Teresa Auriemma · 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

Teresa Auriemma was admitted to hospital after becoming unwell and was treated for aspiration pneumonia, dehydration, acute kidney injury and deranged electrolytes. She received intravenous potassium based on an out-of-date and inaccurate blood test, was given further intravenous potassium without the required monitoring, and subsequently collapsed and died from a fatally high potassium level. The principal concerns were failures to monitor potassium and other electrolytes and to ensure that doctors understood and complied with relevant monitoring policies.

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 ensure doctors are aware of and comply with electrolyte-monitoring policies
Wider context from the report
“1) None of the doctors caring for Mrs. Auriemma from 11.3.24 onwards appear to have heeded the guidance of policy WAHT-PHA-020 for the treatment of hypokalaemia, and in particular that daily monitoring of urea and electrolytes (U&E) was required until the patient’s potassium levels had returned to normal levels. Mrs. Auriemma had been prescribed an oral potassium supplement from 11.3.24. A junior doctor assisting the consultant on the ward round on 15.3.24, when asked what Mrs. Auriemma’s potassium level was, gave the last reading taken on 11.3.24; that junior doctor appeared therefore not to have understood the need for daily U&E monitoring. The consultant accepted he should have checked the date of the reading given, but did not and instead assumed it was up-to-date. The consultant then proceeded to prescribe intravenous potassium on 15.3.24; 2) Once the intravenous potassium had been given on 15.3.24, further U&E monitoring should have been carried out before any more intravenous potassium was given. That U&E monitoring was not done, and instead further intravenous potassium was given on 16.3.24. No clear reason was provided to the inquest as to why the junior doctor responsible had not checked Mrs. Auriemma’s potassium levels before prescribing further intravenous potassium; 3) This is not the first inquest which has found shortcomings in the Trust’s monitoring of patients’ electrolyte levels. Only 2 months ago, this court heard evidence in another inquest concerning the death of a young woman at Worcestershire Royal Hospital in January 2024, who had died because staff at the hospital had failed to recognize and act upon an excessively low sodium level. In that case, like this, I found that there was a failure by doctors to ensure proper monitoring of electrolytes by checking blood results before prescribing IV fluids. 4) I am therefore concerned that the Trust has not ensured that its doctors: (a) understand the importance generally of U&E monitoring before prescribing intravenous fluids; and (b) are aware of, and comply with specific policies concerning this issue, such as that relating to the management of hypokalaemia ( WAHT-PHA-020 ). ”
Source location
Teresa Auriemma · Prevention of Future Deaths report
Page 1 · 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
Failure to ensure doctors understand the importance of U&E monitoring before prescribing intravenous fluids
Wider context from the report
“1) None of the doctors caring for Mrs. Auriemma from 11.3.24 onwards appear to have heeded the guidance of policy WAHT-PHA-020 for the treatment of hypokalaemia, and in particular that daily monitoring of urea and electrolytes (U&E) was required until the patient’s potassium levels had returned to normal levels. Mrs. Auriemma had been prescribed an oral potassium supplement from 11.3.24. A junior doctor assisting the consultant on the ward round on 15.3.24, when asked what Mrs. Auriemma’s potassium level was, gave the last reading taken on 11.3.24; that junior doctor appeared therefore not to have understood the need for daily U&E monitoring. The consultant accepted he should have checked the date of the reading given, but did not and instead assumed it was up-to-date. The consultant then proceeded to prescribe intravenous potassium on 15.3.24; 2) Once the intravenous potassium had been given on 15.3.24, further U&E monitoring should have been carried out before any more intravenous potassium was given. That U&E monitoring was not done, and instead further intravenous potassium was given on 16.3.24. No clear reason was provided to the inquest as to why the junior doctor responsible had not checked Mrs. Auriemma’s potassium levels before prescribing further intravenous potassium; 3) This is not the first inquest which has found shortcomings in the Trust’s monitoring of patients’ electrolyte levels. Only 2 months ago, this court heard evidence in another inquest concerning the death of a young woman at Worcestershire Royal Hospital in January 2024, who had died because staff at the hospital had failed to recognize and act upon an excessively low sodium level. In that case, like this, I found that there was a failure by doctors to ensure proper monitoring of electrolytes by checking blood results before prescribing IV fluids. 4) I am therefore concerned that the Trust has not ensured that its doctors: (a) understand the importance generally of U&E monitoring before prescribing intravenous fluids; and (b) are aware of, and comply with specific policies concerning this issue, such as that relating to the management of hypokalaemia ( WAHT-PHA-020 ). ”
Source location
Teresa Auriemma · 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
Issue an advisory notice reminding doctors to follow NICE guidance when prescribing intravenous fluids and monitoring electrolytes.

Verbatim wording from the response
“i. An advisory notice has gone out to all doctors to remind them to prescribe IV fluids and monitor electrolytes as per NICE guidance (which are printed on the reverse of every intravenous fluid prescription sheet).”

Source location
Response from Worcestershire Acute Hospitals NHS Trust
Page 1 · response
Published 19 November 2024
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
Operate a working party to examine non-compliance with fluid-monitoring standards and address identified knowledge or skills gaps.

Verbatim wording from the response
“ii. A working party has been set up to examine the reasons for non-compliance with these standards, and to address any knowledge or skills gap that is identified.”

Source location
Response from Worcestershire Acute Hospitals NHS Trust
Page 1 · response
Published 19 November 2024
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
Improve the intranet’s policy visibility and search function so electrolyte-correction policies are readily available.

Verbatim wording from the response
“ii. The Trust has improved the visibility and search function of the Trust’s intranet page so that policies are readily available on demand.”

Source location
Response from Worcestershire Acute Hospitals NHS Trust
Page 1 · response
Published 19 November 2024
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
Require all Trust doctors to undertake continuing professional development on electrolyte balance.

Verbatim wording from the response
“iii. There are planned actions to get all of the doctors in the Trust to do some Continued Professional Development (CPD) on electrolyte balance”

Source location
Response from Worcestershire Acute Hospitals NHS Trust
Page 1 · response
Published 19 November 2024
Open published response
25 Jul2014
Surrey
Concerns raised1
1. No established GP practice system for recognition, assessment and management of electrolyte abnormalities
This report raised 13 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 1
1. Action
  Highlight to all clinicians the importance of monitoring, assessing and appropriately following up electrolyte abnormalities.
  Stated by Woodlands SurgeryStated completed
Respondent positions 1
1. Position
  No specific system changes to handle abnormal pathology results can be implemented; clinicians have instead been reminded to monitor, assess and follow up abnormalities.
  Stated by Woodlands SurgeryUnable to act
AI-generated summary

Clare Serena Anke COOPER · 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

Clare Serena Anke Cooper, a young adult, developed weight loss, lassitude, dizziness, nausea, difficulty eating and an intermittently low blood sodium level before dying after a cardiorespiratory arrest and hospital admission. The inquest concluded that she died from the consequences of undiagnosed Addison’s disease and an Addisonian crisis. Principal concerns included inadequate assessment and documentation in primary care, failure to investigate the low sodium and possible physical causes, insufficient eating-disorder service triage processes, and inadequate information available for the post-mortem examination.

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
No established GP practice system for recognition, assessment and management of electrolyte abnormalities
Wider context from the report
“4. No established system for recognition, assessment and management of electrolyte abnormalities within the GP practice and/or consideration of the chemical pathology service to ‘flag-up’ particularly concerning results. ”
Source location
Clare Serena Anke COOPER · Prevention of Future Deaths report
Page 3 · 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
Highlight to all clinicians the importance of monitoring, assessing and appropriately following up electrolyte abnormalities.

Verbatim wording from the response
“handle abnormal pathology results as a result of this case. Unfortunately we do not consider that there are any specific system changes that can be implemented but I have highlighted to all clinicians the importance of monitoring and assessing electrolyte abnormalities and appropriate follow up.”

Source location
2014-0345-Response-by-Woodlands-Surgery
Page 3 · response
Published 25 July 2014
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
No specific system changes to handle abnormal pathology results can be implemented; clinicians have instead been reminded to monitor, assess and follow up abnormalities.

Verbatim wording from the response
“The system at the practice at the time for identifying abnormal electrolyte results was that all results are seen by the patients’ usual registered doctor. It is the responsibility of the patients’ usual registered doctor to action and file the results. In relation to this case the results were seen and filed by Miss Cooper’s registered doctor. Miss Cooper was reviewed here at the practice within a week of each abnormal electrolyte result. The practice has considered what if any specific changes can be made to the way in which we”

Source location
2014-0345-Response-by-Woodlands-Surgery
Page 2 · response
Published 25 July 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to ensure doctors are aware of and comply with electrolyte-monitoring policies

Failure to ensure doctors understand the importance of U&E monitoring before prescribing intravenous fluids

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.4

Concerns raised1

No established GP practice system for recognition, assessment and management of electrolyte abnormalities

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.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 4

Actions described in response 1

Respondent positions 1