Recurring concern

Failure to provide clinically required fluids

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First reported 9 Sep 2014•Latest report 7 Feb 2026

Definition

What this concern includes

Includes failures to provide, administer or maintain clinically required oral or intravenous fluids, including prolonged or repeated omissions and inadequate provision where the need for fluids is identified by the patient's condition, prescription or care plan.

Not included

  • Excludes failures limited to fluid-balance recording, review, electrolyte monitoring or escalation when fluid provision itself was adequate.
  • Excludes generic staffing, communication, documentation or bed-capacity deficiencies unless they directly result in failure to provide clinically required fluids.
  • Excludes failures concerning unrelated treatments, medicines or nutritional provision where fluids are not the shared unsafe condition.
  • Excludes fluid restriction or withholding when it is clinically indicated and safely managed.
Reports
11

Distinct published reports

Individual concerns
12

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
7

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Blackpool Teaching Hospitals NHS Foundation Trust1
Care Quality Commission1
Cwm Taf Morgannwg University Local Health Board1
Department of Health and Social Care1
Greater Manchester Mental Health NHS Foundation Trust1
Hinchingbrooke Hospital1
North Cumbria Integrated Care NHS Foundation Trust1
Pennine Acute Hospitals NHS Trust1
Sheffield Teaching Hospitals NHS Foundation Trust1
Stockport NHS Foundation Trust1
University Hospitals of North Midlands NHS Trust1
University Hospitals Sussex NHS Foundation Trust1
York and Scarborough Teaching Hospitals NHS Foundation 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.

  1. South and West Cambridgeshire

    AI-generated summary

    Anne Elizabeth Sandever · 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

    Anne Elizabeth Sandever, a diabetic woman with acute on chronic renal failure, was admitted to hospital on 3 February 2014, deteriorated after transfer to Walnut ward, and died on 6 February 2014. The concerns included gaps in nursing and medical observation, poor communication and handover about her diabetes, lack of intravenous fluids despite renal failure, and insufficient investigation of the incident.

    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 provide intravenous fluids to patients with renal failure

    Wider context from the report

    “(3) She was left without intravenous fluids for many hours despite having renal failure. ”

    Source location

    Anne Elizabeth Sandever · Prevention of Future Deaths report
    Page 1 · 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

    Recirculate NICE guidance and the ALERT on acute kidney injury to nursing and medical staff.

    Verbatim wording from the response

    “Please see the response to concern 1 above, as the actions incorporate this issue. In addition, the investigating team recommended specific work around raising awareness of Acute Kidney Injury (AKI) in chronic renal patients. We have, therefore, re-circulated NICE guidance and a subsequent ALERT around AKI to all nursing and medical staff, through which we are raising awareness of the significance of a lack of urine output and fluid replacement in patients with Chronic Renal Failure in an acute episode. Minutes of Critical Care meetings have confirmed circulation and we will include AKIs in our review of incidents.”

    Source location

    2014-0393-Response_Redacted
    Page 2 · response
    Published 4 September 2014

    Open published response
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Data last updated 7 September 2026