Recurring concern

Failure to reliably monitor patient fluid balance

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First reported 28 Aug 2013•Latest report 22 Dec 2025

Definition

What this concern includes

Includes failures of the dedicated patient fluid-balance monitoring process, including failure to initiate, assess, measure, record or maintain monitoring, and delayed or incomplete monitoring when fluid status is clinically important.

Not included

Excludes failures limited to recording fluid-balance information when monitoring itself was completed reliably.
Excludes generic clinical information, staffing or documentation deficiencies unless they directly cause failure of the patient fluid-balance monitoring process.
Excludes monitoring of other physiological measures unless the assertion specifically concerns patient fluid balance.
Excludes treatment or fluid-management decisions where no failure of fluid-balance monitoring is identified.

Reports: 29
Individual concerns: 34
Date range: 2013–2025
Stated actions: 78

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 Commission3

Ashford and St Peter'S Hospitals NHS Foundation Trust2

Blackpool Teaching Hospitals NHS Foundation Trust2

Department of Health and Social Care2

NHS England2

Swansea Bay University Local Health Board2

University Hospitals Sussex NHS Foundation Trust2

Aneurin Bevan University LHB1

Barking, Havering and Redbridge University Hospitals NHS Trust1

Barts Health NHS Trust1

Cwm Taf Morgannwg University Local Health Board1

East Kent Hospitals University NHS Foundation Trust1

East Surrey Hospital1

Epsom Hospital1

General Medical Council1

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.

22 Jul2021
West Yorkshire Eastern
Concerns raised2
1. Failure to create a plan for monitoring fluid and food intake
2. Failure to place an instruction in the room to prompt monitoring
This report raised 5 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

John Dickinson · 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

John Dickinson was admitted to hospital after falls and treatment for a gall bladder infection, then moved to a care home. He later developed poor nutritional and fluid intake, dehydration, acute kidney impairment and a urinary tract infection, and died on 9 August 2020 while receiving palliative care. Concerns included inconsistent and insufficiently detailed record keeping, failures to document or act on advice about monitoring food and fluid intake, and delayed recognition of deterioration.

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 create a plan for monitoring fluid and food intake
Wider context from the report
“(1) The record keeping was inconsistent and lacked detail on general wellbeing. (2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained. (3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020. (4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned. (5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring. (6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal. ”
Source location
John Dickinson · 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
Failure to place an instruction in the room to prompt monitoring
Wider context from the report
“(1) The record keeping was inconsistent and lacked detail on general wellbeing. (2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained. (3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020. (4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned. (5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring. (6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal. ”
Source location
John Dickinson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Oct2020
Blackpool and the Fylde
Concerns raised1
1. Failure to complete prescription and fluid balance charts for prescribed fluids
This report raised 7 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 2
1. Action
  Conduct regular Emergency Department spot audits and huddles to verify NEWS2 recording, prompt escalation and completion of fluid charts.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated planned
2. Action
  Complete daily real-time Consistency in Care Audits reviewing NEWS2 and fluid-balance compliance and manage identified inconsistencies.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completed
AI-generated summary

Douglas OWENS · 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

Douglas Robert Owens developed acute cardiac failure, hypotension, aspiration pneumonia and multi-organ failure after cataract surgery, treatment for raised intraocular pressure, ongoing eye pain and painful urinary retention. He died in intensive care on 7 July 2018. Concerns included arrangements for urgent ophthalmic transfer, specialist assessment, monitoring and review of deterioration, fluid documentation, and recording medication doses.

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 complete prescription and fluid balance charts for prescribed fluids
Wider context from the report
“(5)That the evidence disclosed the fact that, whilst fluids had been prescribed, no prescription chart or fluid balance chart had been completed. Unless action is taken to ensure the completion of applicable documentation, the lives of patients may be put at risk. ”
Source location
Douglas OWENS · 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
Conduct regular Emergency Department spot audits and huddles to verify NEWS2 recording, prompt escalation and completion of fluid charts.

Verbatim wording from the response
“In the interim, the Head of the Emergency Department and the Matron will ensure senior clinical staff will undertake regular spot audits / huddles, to ensure all patients in the ED have their NEWS2 score recorded correctly, that any changes in score are acted upon promptly and that fluid charts are completed correctly and acted upon promptly. The ED complete a Consistency in Care Audit daily, where 40 patients’ notes (approximately 20% of all patients daily) are reviewed in real time and this includes a review of the NEWS 2 and fluid balance. This is used to monitor the compliance and manage any inconsistencies in care at the time. Additionally the ED undertakes an intentional round, where all patients who have been in the department for longer than 4 hours, are reviewed by the EPIC (Emergency Physician in Charge) to ensure that appropriate plans of care are in place.”

Source location
2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
Page 3 · response
Published 3 December 2020
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
Complete daily real-time Consistency in Care Audits reviewing NEWS2 and fluid-balance compliance and manage identified inconsistencies.

Verbatim wording from the response
“In the interim, the Head of the Emergency Department and the Matron will ensure senior clinical staff will undertake regular spot audits / huddles, to ensure all patients in the ED have their NEWS2 score recorded correctly, that any changes in score are acted upon promptly and that fluid charts are completed correctly and acted upon promptly. The ED complete a Consistency in Care Audit daily, where 40 patients’ notes (approximately 20% of all patients daily) are reviewed in real time and this includes a review of the NEWS 2 and fluid balance. This is used to monitor the compliance and manage any inconsistencies in care at the time. Additionally the ED undertakes an intentional round, where all patients who have been in the department for longer than 4 hours, are reviewed by the EPIC (Emergency Physician in Charge) to ensure that appropriate plans of care are in place.”

Source location
2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
Page 3 · response
Published 3 December 2020
Open published response
10 Mar2020
Central and South East Kent
Concerns raised1
1. Failure to accurately complete and reconcile fluid balance charts
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 5
1. Action
  Support clinical leadership teams to understand roles and responsibilities for accurate fluid-balance monitoring.
  Stated by East Kent Hospitals University NHS Foundation TrustStated completed
2. Action
  Deliver multidisciplinary education on the importance of accurate fluid-balance monitoring.
  Stated by East Kent Hospitals University NHS Foundation TrustStated completed
3. Action
  Audit fluid-balance chart completion and monitor results through the Deteriorating Patient Group, with ward managers responsible for improvement.
  Stated by East Kent Hospitals University NHS Foundation TrustStated completed
1. Action
  Provide clinical induction training on completing and reviewing fluid-balance charts daily.
  Stated by East Kent Hospitals University NHS Foundation TrustStated completed
2. Action
  Provide ward staff with critical-care outreach support and teaching on completing fluid-balance charts.
  Stated by East Kent Hospitals University NHS Foundation TrustStated completed
AI-generated summary

Lynda Pedersen · 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

Lynda Pedersen died on 7 September 2018 in hospital from aspiration pneumonitis, pneumonia and fluid overload due to a stricture caused by an adenocarcinoma of the oesophagogastric junction. The adenocarcinoma was not identified during her admission or during earlier medical care following an admission for dysphagia. Concerns included the lack of a pathway for investigating dysphagia caused by a stricture, which contributed to the need to investigate malignancy being lost, and deficiencies in fluid balance charting and recording of fluid output before her death.

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 accurately complete and reconcile fluid balance charts
Wider context from the report
“(2) Fluid balance charts were not correctly completed in the period leading to Lynda Pedersen’s death. The evidence from the fluid balance charts showed that she was carrying fluids forward until the time of her death; there being an imbalance to the tune of some 3 1/2 litres. That there was a significant fluid overload was also evident from the pathology. That she had a fluid overload was only identified by the hospital at a time that she was temporally close to death. It was accepted at the inquest that the charts were deficient in their completion, that nursing staff had not recorded output properly or reconciled the balance as required. ”
Source location
Lynda Pedersen · 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
Support clinical leadership teams to understand roles and responsibilities for accurate fluid-balance monitoring.

Verbatim wording from the response
“The Trust is focused on improving how we monitor fluid balance through the completion of fluid balance charts in all areas of the Trust. We have addressed this through supporting our clinical leadership teams in understanding their roles and responsibilities to ensure best practice in their wards by medical and nursing teams. We have undertaken multi-disciplinary education programmes on the importance of accurate fluid balance monitoring and regularly audit of the completion of fluid balance charts. Our Deteriorating Patient Group leads on monitoring audit results regarding accurate completion of fluid balance charts with ward managers taking responsibility for their results and making improvement where required.”

Source location
2020-0112-Response-from-East-Kent-Hospitals-Trust.pdf
Page 2 · response
Published 10 June 2020
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 multidisciplinary education on the importance of accurate fluid-balance monitoring.

Verbatim wording from the response
“The Trust is focused on improving how we monitor fluid balance through the completion of fluid balance charts in all areas of the Trust. We have addressed this through supporting our clinical leadership teams in understanding their roles and responsibilities to ensure best practice in their wards by medical and nursing teams. We have undertaken multi-disciplinary education programmes on the importance of accurate fluid balance monitoring and regularly audit of the completion of fluid balance charts. Our Deteriorating Patient Group leads on monitoring audit results regarding accurate completion of fluid balance charts with ward managers taking responsibility for their results and making improvement where required.”

Source location
2020-0112-Response-from-East-Kent-Hospitals-Trust.pdf
Page 2 · response
Published 10 June 2020
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
Audit fluid-balance chart completion and monitor results through the Deteriorating Patient Group, with ward managers responsible for improvement.

Verbatim wording from the response
“The Trust is focused on improving how we monitor fluid balance through the completion of fluid balance charts in all areas of the Trust. We have addressed this through supporting our clinical leadership teams in understanding their roles and responsibilities to ensure best practice in their wards by medical and nursing teams. We have undertaken multi-disciplinary education programmes on the importance of accurate fluid balance monitoring and regularly audit of the completion of fluid balance charts. Our Deteriorating Patient Group leads on monitoring audit results regarding accurate completion of fluid balance charts with ward managers taking responsibility for their results and making improvement where required.”

Source location
2020-0112-Response-from-East-Kent-Hospitals-Trust.pdf
Page 2 · response
Published 10 June 2020
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
Provide clinical induction training on completing and reviewing fluid-balance charts daily.

Verbatim wording from the response
“In addition, all our clinical staff complete clinical induction days to ensure they understand the importance of completing fluid balance charts and reviewing these daily and our critical care outreach teams provide support and teaching to ward staff on the importance of completing fluid balance. This concludes our response to your concern.”

Source location
2020-0112-Response-from-East-Kent-Hospitals-Trust.pdf
Page 2 · response
Published 10 June 2020
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
Provide ward staff with critical-care outreach support and teaching on completing fluid-balance charts.

Verbatim wording from the response
“In addition, all our clinical staff complete clinical induction days to ensure they understand the importance of completing fluid balance charts and reviewing these daily and our critical care outreach teams provide support and teaching to ward staff on the importance of completing fluid balance. This concludes our response to your concern.”

Source location
2020-0112-Response-from-East-Kent-Hospitals-Trust.pdf
Page 2 · response
Published 10 June 2020
Open published response
29 Mar2019
Manchester City
Concerns raised1
1. Failure to complete fluid balance charts accurately and consistently
This report raised 4 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Ann Corfield · 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

Ann Corfield was admitted to hospital with a urinary tract infection, low sodium levels and deteriorating mental health, later developing severe psychotic depression, poor oral intake and dehydration. She suffered a cardiac arrest and died after transfer between hospitals. Concerns included inadequate handover about anticoagulation, failure to administer prescribed prophylactic anticoagulation, poor completion of fluid balance charts, and the lack of suitably qualified staff to administer intravenous fluids at Park House.

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 complete fluid balance charts accurately and consistently
Wider context from the report
“2. Dehydration clearly played a part in Mrs Corfield’s death. I heard evidence at Inquest that Fluid Balance Charts were poorly completed indeed some of them were not completed at all or contained errors with simple arithmetic. At the Inquest, I heard conflicting evidence about the usefulness of fluid balance charts. Witnesses who were employed by Pennine Acute Trust tended to place more reliance on the results of blood tests. However, ████████ emphasised to me the importance of FBC charts in a patient like Mrs Corfield who had a history of chronic kidney disease because blood tests were an ‘insensitive measure’ of hydration. I received helpful written evidence from ████████ who is the Divisional Director of Nursing for Medicine at Royal Oldham Hospital, dated 31st January 2019, which, at paragraph 17, shows there are still ongoing problems with the way fluid balance charts are completed some two and a half years after Mrs Corfield’s death. ”
Source location
Ann Corfield · Prevention of Future Deaths report
Page 3 · concerns
Open source report
10 Jan2019
Manchester South
Concerns raised1
1. Failure to complete fluid balance charts and calculate fluid position
This report raised 12 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
  Introduced bedside signage identifying patients with fluid balance charts.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
2. Action
  Added a Trust-wide fluid balance chart compliance audit to the 2019/2020 Audit Programme.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated planned
3. Action
  Distributed a learning bulletin on monitoring and completing fluid balance charts.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
AI-generated summary

Michael William Flynn · 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

Michael William Flynn underwent elective hip replacement surgery and required a blood transfusion. He subsequently experienced inadequate Early Warning Score monitoring, failures to follow escalation procedures, incomplete fluid-balance monitoring, and a lack of timely clinical review before suffering cardiac arrest and dying on 17 July 2018.

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 complete fluid balance charts and calculate fluid position
Wider context from the report
“10. A fluid balance chart was requested and fluids prescribed. It was not completed fully and in particular the necessary calculations to understand Mr Flynn's fluid position were not made. The trust policy was not followed regarding completion. The doctor who saw Mr Flynn on the morning of 16th July 2018 prescribed further fluids without reference to the fluid charts. ”
Source location
Michael William Flynn · 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
Introduced bedside signage identifying patients with fluid balance charts.

Verbatim wording from the response
“In regard to the fluid balance chart, I have been assured by the Matron for the Orthopaedic Unit that formal discussions have taken place with the nursing staff identified as failing to comply with Trust Policy in respect to the completion of the fluid balance chart and consideration given to identify support or training needs. In addition, the newsletter previously referred to, circulated to all staff in the department, reiterates staff responsibilities and accountability regarding completion of the fluid balance chart. As an additional measure, I understand the ward manager has recently introduced new signage placed at the bedside to further support staff in recognizing which patients have a fluid balance chart in place.”

Source location
2019-0008-Response-by-Tameside-and-Glossop-Care-NHS-Trust
Page 5 · response
Published 23 May 2019
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
Added a Trust-wide fluid balance chart compliance audit to the 2019/2020 Audit Programme.

Verbatim wording from the response
“I am aware that an audit of fluid balance charts has recently been completed, as part of a wider audit of the Trust’s Acute Kidney Injury care pathway. The results identify 100% compliance in completion of the fluid balance chart. Whilst this provides a level of assurance, the Head of Clinical Audit and Effectiveness has indicated that a trust wide audit of fluid balance chart compliance has been added to the Trust Audit Programme for 2019/2020.”

Source location
2019-0008-Response-by-Tameside-and-Glossop-Care-NHS-Trust
Page 5 · response
Published 23 May 2019
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
Distributed a learning bulletin on monitoring and completing fluid balance charts.

Verbatim wording from the response
“The Medical Education Manager has advised that fluid balance management is included in the AIMS training that is provided to junior doctors commencing at the Trust and the Patient Safety Team have drafted and distributed a ‘Time out for Learning’ bulletin focusing on the importance of monitoring and completing fluid balance charts.”

Source location
2019-0008-Response-by-Tameside-and-Glossop-Care-NHS-Trust
Page 5 · response
Published 23 May 2019
Open published response
23 Oct2018
Brighton and Hove
Concerns raised1
1. Failure to maintain an accurate fluid balance chart and measure urine output
This report raised 11 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Kalma RAM-HENMAN · 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

Kalma RAM-HENMAN died on 7 June 2018 after presenting to A&E in a precarious state and later being found to have a perforated gastric ulcer. The report identified concerns about incomplete fluid monitoring, failure to administer prescribed potassium and sufficient intravenous fluids, missed ECG abnormalities, inadequate repeat blood testing, and delays in responding to her deterioration and providing planned treatment.

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 maintain an accurate fluid balance chart and measure urine output
Wider context from the report
“(1) This lady arrived in A&E in a “precarius” state as the blood test results revealed and there were several failings:- The attending Doctor required an accurate fluid chart. This was started. It was incompletely filled out and showed no output and no attempts were made to measure urine output. As a result, Doctors and Nurses were unaware of just how dehydrated Mrs RAM-HENMAN was becoming. ”
Source location
Kalma RAM-HENMAN · Prevention of Future Deaths report
Page 1 · concerns
Open source report
27 Jun2018
Inner North London
Concerns raised1
1. Lack of fluid balance chart availability
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Angela Sandra Ivina West · 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

Angela Sandra Ivina West had end stage kidney disease and underwent gall bladder removal surgery on 6 July 2017. She deteriorated over the following days, with tachycardia, acidosis, hyperkalaemia and hypovolemia, and died after suffering a cardiac arrest on 9 July 2017. Concerns included weekend staffing arrangements, her care on a general surgical ward, and the absence of fluid balance charts in relation to dehydration.

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
Lack of fluid balance chart availability
Wider context from the report
“(3) The investigation highlighted issues relating to Ms West becoming dehydrated. Neither myself nor the clinical investigators were able to locate any fluid balance charts for Ms West. ”
Source location
Angela Sandra Ivina West · Prevention of Future Deaths report
Page 2 · concerns
Open source report
12 Jun2018
Surrey
Concerns raised1
1. Failure to create a coherent plan for managing diabetes insipidus and related fluid balance
This report raised 9 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 4
1. Action
  Develop a pro-forma documenting hyponatraemia monitoring plans, including sodium targets, risks of rapid correction and when to consider restarting desmopressin.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated in progress
2. Action
  Review the Trust-wide process for managing patients’ fluid balance charts.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated in progress
3. Action
  Introduce a training programme for fluid balance chart management following the process review.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated planned
1. Action
  Classify desmopressin as a high-risk drug requiring specialist advice before discontinuation and a plan for reintroduction.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated completed
AI-generated summary

Rita 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

Rita Taylor was admitted to hospital with severe hyponatraemia in the context of diabetes insipidus and a pituitary adenoma, and died on 15 August 2017 after developing central pontine myelinolysis. The principal concerns were failures to appropriately monitor and manage her sodium levels and diabetes insipidus, including omission of desmopressin, inadequate fluid-balance assessment, insufficient documentation, and lack of a coherent management plan.

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 create a coherent plan for managing diabetes insipidus and related fluid balance
Wider context from the report
“3. The failure, at any time between the 31st July 2017 until the 6th August 2017 to create a coherent plan for the management of Mrs Taylors medical problems resulting in the failure to assess fluid balance or to reintroduce desmopressin, given a known diagnosis of diabetes insipidus on a background of a pituitary adenoma. ”
Source location
Rita Taylor · Prevention of Future Deaths report
Page 4 · 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
Develop a pro-forma documenting hyponatraemia monitoring plans, including sodium targets, risks of rapid correction and when to consider restarting desmopressin.

Verbatim wording from the response
“Response - The AMU lead within the Trust is devising a new pro-forma for the documentation of monitoring plans for patients. Recommendation 6 of the RCA report specifies the need for the monitoring plan for patients with hyponatraemia to set out the desired rate of rise of that patient’s sodium and the risks associated with a rise steeper than this. The monitoring plan will also set out when to consider restarting medication such as desmopressin. The Trust has also set up a Task and Finish Group to review the feasibility of cohorting patients needing the highest acuity of care, (which would include those patients who need regular blood tests), with the ambition that these patients are placed in a specialist ward area from April 2019 to facilitate more regular reviews of their management.”

Source location
2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 2018
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
Review the Trust-wide process for managing patients’ fluid balance charts.

Verbatim wording from the response
“The Trust has also set up a Task and Finish Group to review the process for managing the fluid balance charts of all patients in the Trust and a programme of training will be introduced following this review - see Recommendation 7 of the Action Plan.”

Source location
2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Page 4 · response
Published 23 September 2018
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
Introduce a training programme for fluid balance chart management following the process review.

Verbatim wording from the response
“The Trust has also set up a Task and Finish Group to review the process for managing the fluid balance charts of all patients in the Trust and a programme of training will be introduced following this review - see Recommendation 7 of the Action Plan.”

Source location
2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Page 4 · response
Published 23 September 2018
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
Classify desmopressin as a high-risk drug requiring specialist advice before discontinuation and a plan for reintroduction.

Verbatim wording from the response
“Response - Recommendation 5 of the Action Plan sets out that; ‘Desmopressin should be notified as a high risk drug that should not be discontinued without specialist advice.’ The specialist providing the advice to discontinue the drug will ensure that there is a plan in place to reintroduce the drug at an appropriate time. This action has been implemented by the Medicines Management Committee with input from the pharmacy department.”

Source location
2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Page 4 · response
Published 23 September 2018
Open published response
12 Oct2017
Manchester West
Concerns raised1
1. Delays in implementing fluid balance monitoring
This report raised 7 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Carol Buchanan · 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

Carol Buchanan was admitted to hospital after a fall and later deteriorated following the combined prescription of Itraconazole and Simvastatin, which led to rhabdomyolysis and muscle necrosis. She died on 26 May 2017 despite treatment. Concerns included inadequate prescription record checking and documentation, failure to recognise the serious drug interaction, missed opportunities to act on relevant history, and delays in monitoring and diagnosis.

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Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in implementing fluid balance monitoring
Wider context from the report
“5. In the Division of Tracheobronchial and Sinusitis, it was noted that the correct diagnosis was assisted with further information from the patient and family from the 21st May 2017 and the family had repeatedly presented the specific information of circumstances that demonstrates that the concerns were not noted adequately: a. The importance of the history not appreciated upon; b. Missed opportunities between and 27th May 2017 to act on the history not appreciated or acted upon; c. Delay in implementing delivery of fluid balance monitoring; and d. delay in specific diagnosis of the underlying cause of the patients presenting symptoms. ”
Source location
Carol Buchanan · Prevention of Future Deaths report
Page 2 · concerns
Open source report
26 Sep2017
South Wales Central
Concerns raised3
1. Failure to recognise and escalate absent urine output
2. Failure to actively monitor urine output
3. Failure to use fluid balance charts to monitor fluid intake and urine output
This report raised 5 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Hedley Greenland · 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

Hedley Greenland, who was residing in a nursing home and had prostate cancer requiring permanent catheterisation, became acutely unwell on 17 December 2016 and died in hospital on 20 December 2016. The inquest concluded that he died from the effects of a urine infection in circumstances where fluid input and catheter output were not adequately monitored for over nine hours. Concerns included the absence of fluid balance monitoring and written handover, inadequate catheter-care training and knowledge, and the absence of evidence that the Catheter Care Bundle was being used.

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 and escalate absent urine output
Wider context from the report
“(1) A fluid balance chart should have been used by nursing staff to monitor fluid intake and urine output. There was no evidence that one had been thus rendering it impossible to measure urine output which might have indicated a blockage and/or infection. It was apparent during the course of the evidence that the nurse in charge of Mr Greenland's care did not consider actively monitoring his urine output, neither did she consider flushing the catheter. There was no written handover, as the evidence showed is normally the practice, to the incoming nursing team the following morning. There was no clear evidence that the lack of urine output had been noted by the night shift with a view to escalating his care. The evidence revealed that there was no urine output for at least 9 hours but probably substantially more than that. ”
Source location
Hedley Greenland · 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
Failure to actively monitor urine output
Wider context from the report
“(1) A fluid balance chart should have been used by nursing staff to monitor fluid intake and urine output. There was no evidence that one had been thus rendering it impossible to measure urine output which might have indicated a blockage and/or infection. It was apparent during the course of the evidence that the nurse in charge of Mr Greenland's care did not consider actively monitoring his urine output, neither did she consider flushing the catheter. There was no written handover, as the evidence showed is normally the practice, to the incoming nursing team the following morning. There was no clear evidence that the lack of urine output had been noted by the night shift with a view to escalating his care. The evidence revealed that there was no urine output for at least 9 hours but probably substantially more than that. ”
Source location
Hedley Greenland · 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
Failure to use fluid balance charts to monitor fluid intake and urine output
Wider context from the report
“(1) A fluid balance chart should have been used by nursing staff to monitor fluid intake and urine output. There was no evidence that one had been thus rendering it impossible to measure urine output which might have indicated a blockage and/or infection. It was apparent during the course of the evidence that the nurse in charge of Mr Greenland's care did not consider actively monitoring his urine output, neither did she consider flushing the catheter. There was no written handover, as the evidence showed is normally the practice, to the incoming nursing team the following morning. There was no clear evidence that the lack of urine output had been noted by the night shift with a view to escalating his care. The evidence revealed that there was no urine output for at least 9 hours but probably substantially more than that. ”
Source location
Hedley Greenland · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to create a plan for monitoring fluid and food intake

Failure to place an instruction in the room to prompt monitoring

Concerns raised1

Failure to complete prescription and fluid balance charts for prescribed 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.2

Concerns raised1

Failure to accurately complete and reconcile fluid balance charts

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.5

Concerns raised1

Failure to complete fluid balance charts accurately and consistently

Concerns raised1

Failure to complete fluid balance charts and calculate fluid position

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

Concerns raised1

Failure to maintain an accurate fluid balance chart and measure urine output

Concerns raised1

Lack of fluid balance chart availability

Concerns raised1

Failure to create a coherent plan for managing diabetes insipidus and related fluid balance

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

Delays in implementing fluid balance monitoring

Actions described in response 2

Actions described in response 5

Actions described in response 3

Actions described in response 4