Recurring concern

Unsafe intravenous fluid management

First to latest report 10 Mar 2014 — 7 Apr 2025

Reports that mention this concern: 11
Times this concern has been raised: 14
Stated actions linked to this concern: 18

What this concern includes

Includes failures of controls dedicated to intravenous fluid management, including assessment before prescribing, dose or bolus selection, monitoring of relevant clinical results, reassessment after administration and escalation when treatment risks or response require review.

What is not included

Excludes failures involving oral or enteral fluids where intravenous fluid therapy is not materially involved.
Excludes generic monitoring, prescribing or clinical-review deficiencies that are not specifically tied to intravenous fluid management.
Excludes failures limited to cannula equipment, infusion delivery or fluid-balance recording unless they directly concern the safe management of intravenous fluid therapy.
Excludes treatment decisions concerning electrolytes or other conditions where intravenous fluid management is not the identified unsafe process.

Trends

Reports over time

Reports mentioning this concern, 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.

Department of Health and Social Care2

NHS Central East Integrated Care Board2

Tameside and Glossop Integrated Care NHS Foundation Trust2

Worcestershire Acute Hospitals NHS Trust2

Care Quality Commission1

Cornwall Partnership NHS Foundation Trust1

Department for Digital, Culture, Media and Sport1

Faculty of Intensive Care Medicine1

General Medical Council1

Medway NHS Foundation Trust1

Milton Keynes University Hospital1

National Institute for Health and Care Excellence1

NHS Bedfordshire, Luton and Milton Keynes Integrated Care Board1

NHS Surrey and Sussex Integrated Care Board1

Northamptonshire Safeguarding Children Partnership1

Reports and published responses 11 reports

See individual reports that have raised this concern, and the actions taken in response

7 Apr2025
Cambridgeshire and Peterborough
Concerns raised1
1. Failure to target intravenous fluid management against patient response
This report raised 21 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

NHS Central East Integrated Care Board
North West Anglia NHS Foundation Trust
Royal College of Emergency Medicine
Stated actions 1
1. North West Anglia NHS Foundation Trust
  Deliver training and education on fluid management and maintaining fluid-balance charts.
Respondent positions 3
1. Royal College of Emergency Medicine
  Initial clinical management was appropriate because infection or sepsis was more likely than the much less likely diagnosis of cardiomyopathy.
  Disputes the concern
1. NHS Central East Integrated Care Board
  Existing data show fluid management is not recurrent, while ward accreditation and matron audits provide ongoing monitoring and quality improvement.
  Existing arrangements considered sufficient
2. NHS Central East Integrated Care Board
  The Trust remains responsible for sharing emerging fluid-management themes or risks with the ICB through the monthly Integrated Quality Report.
  Redirects responsibility
AI-generated summary

Christian James Gabriel Hobbs · 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

Christian James Gabriel Hobbs, a 17-year-old, suffered an acute deterioration at home and was taken to hospital on 26 December 2017, where he developed cardiac arrest and died after treatment was stopped. The inquest recorded multi-organ failure, cardiogenic shock and arrhythmogenic cardiomyopathy. Concerns included the absence of an echocardiogram before his arrest, non-targeted fluid management, delays in obtaining blood gases, team communication, radiology documentation, differential diagnosis, ECG interpretation, record keeping and emergency-department alarm data retention.

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 target intravenous fluid management against patient response
Wider context from the report
“POINT C - FLUID MANAGEMENT Intravenous fluids were commenced but these were not targeted against response. Christian remained hypotensive and tachycardic despite the fluid administration. This is an area of concern also. ”
Source location
Christian James Gabriel Hobbs · Prevention of Future Deaths report
Page 16 · 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
Deliver training and education on fluid management and maintaining fluid-balance charts.

Verbatim wording from the response
“C. Fluid Management The Trust acknowledges historical concerns regarding fluid management and the maintenance of fluid balance charts, but significant training and education have since been provided. In Christian’s case, gaining intravenous access was challenging due to hypoperfusion caused by cardiogenic shock, resulting in fluids being administered later than ideal, leaving minimal time to evaluate the response.”

Source location
Response from North West Anglia NHS Foundation Trust
Page 2 · response
Published 15 April 2025
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
Initial clinical management was appropriate because infection or sepsis was more likely than the much less likely diagnosis of cardiomyopathy.

Verbatim wording from the response
“From your report, the RCEM feels that the initial clinical management in this case was appropriate given the greater likelihood of infection or sepsis being the cause of Christian’s presentation than the much less likely diagnosis of cardiomyopathy. We further feel that the clinical management plan which prioritised the delivery of time critical therapy followed by an assessment to see if the interventions had been effective was appropriate.”

Source location
Response from Royal College of Emergency Medicine
Page 1 · response
Published 15 April 2025
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
Existing data show fluid management is not recurrent, while ward accreditation and matron audits provide ongoing monitoring and quality improvement.

Verbatim wording from the response
“• From analysis of patient safety data since 2017, fluid management has not emerged as a recurrent theme within North West Anglia NHS Foundation Trust (NWAF T). Furthermore, fluid balance monitoring forms part of the Trust’s ward accreditation programme, which reviews wards against a range of national care standards. It is also embedded within the Trust’s core matron audit programme, ensuring ongoing oversight and quality improvement. The Trust continues to hold the responsibility to ensure that it will share any emerging themes or risks to the ICB in the monthly Integrated Quality Report.”

Source location
Response from Cambridgeshire and Peterborough ICB
Page 2 · response
Published 15 April 2025
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 Trust remains responsible for sharing emerging fluid-management themes or risks with the ICB through the monthly Integrated Quality Report.

Verbatim wording from the response
“• From analysis of patient safety data since 2017, fluid management has not emerged as a recurrent theme within North West Anglia NHS Foundation Trust (NWAF T). Furthermore, fluid balance monitoring forms part of the Trust’s ward accreditation programme, which reviews wards against a range of national care standards. It is also embedded within the Trust’s core matron audit programme, ensuring ongoing oversight and quality improvement. The Trust continues to hold the responsibility to ensure that it will share any emerging themes or risks to the ICB in the monthly Integrated Quality Report.”

Source location
Response from Cambridgeshire and Peterborough ICB
Page 2 · response
Published 15 April 2025
Open published response
14 Nov2024
Worcestershire
Concerns raised2
1. Failure to ensure doctors understand the importance of U&E monitoring before prescribing intravenous fluids
2. Failure to monitor electrolytes 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.
Linked response

Worcestershire Acute Hospitals NHS Trust
Stated actions 4
1. Worcestershire Acute Hospitals NHS Trust
  Issue an advisory notice reminding doctors to follow NICE guidance when prescribing intravenous fluids and monitoring electrolytes.
2. Worcestershire Acute Hospitals NHS Trust
  Operate a working party to examine non-compliance with fluid-monitoring standards and address identified knowledge or skills gaps.
3. Worcestershire Acute Hospitals NHS Trust
  Require all Trust doctors to undertake continuing professional development on electrolyte balance.
1. Worcestershire Acute Hospitals NHS Trust
  Use electronic prescribing technology, where appropriate, to prompt doctors to consider blood-test results before prescribing intravenous fluids.
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 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 individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to monitor electrolytes 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
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
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
Use electronic prescribing technology, where appropriate, to prompt doctors to consider blood-test results before prescribing intravenous fluids.

Verbatim wording from the response
“iii. As the Trust moves towards electronic prescribing, technology is used where appropriate to prompt medical staff to consider blood test results for patients requiring intravenous fluids.”

Source location
Response from Worcestershire Acute Hospitals NHS Trust
Page 1 · response
Published 19 November 2024
Open published response
14 Oct2024
North Yorkshire and York
Concerns raised1
1. Failure to assess and escalate refusal of intravenous fluids
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

York and Scarborough Teaching Hospitals NHS Foundation Trust
Stated actions 2
1. York and Scarborough Teaching Hospitals NHS Foundation Trust
  Introduce a Nucleus fluid assessment for all patients that prompts hydration monitoring according to clinical need.
2. York and Scarborough Teaching Hospitals NHS Foundation Trust
  Update the Food, Nutrition and Hydration Policy to require best-interest decisions on fluid management for patients lacking capacity, in consultation with family or carers.
AI-generated summary

Stephen Frederick DULLING · 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

Stephen Frederick Dulling, who had Parkinson’s disease, symptoms of dementia and swallowing problems, was admitted to York District Hospital and choked while eating toast, subsequently dying from aspiration pneumonia. Concerns included the response to reported risks before admission and multiple nursing-care lapses during his hospital admission, including the appropriateness of his diet, nutritional monitoring, response to choking and incident investigation.

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 assess and escalate refusal of intravenous fluids
Wider context from the report
“4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings – a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity; b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above; c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment; d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids; e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking; f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest. 5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others. ”
Source location
Stephen Frederick DULLING · 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
Introduce a Nucleus fluid assessment for all patients that prompts hydration monitoring according to clinical need.

Verbatim wording from the response
“Since this incident occurred there is a new fluid assessment, as part of the Nucleus digital patient record, which is completed for all patients. This then prompts appropriate hydration monitoring dependant on the level of clinical need. The Food, Nutrition and Hydration Policy clearly states that when a patient lacks capacity a best interest’s decision should be made about ongoing fluid management, in consultation with family or carers.”

Source location
Response from York and Scarborough Teaching Hospitals NHS Foundation Trust
Page 2 · response
Published 15 October 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
Update the Food, Nutrition and Hydration Policy to require best-interest decisions on fluid management for patients lacking capacity, in consultation with family or carers.

Verbatim wording from the response
“It is accepted that the assessment of Mr Dulling’s nutritional needs on admission was not detailed enough and that a food chart was not instigated/completed when it should have been. The Trust’s Food, Nutrition and Hydration Policy (available if required) was updated in November 2024. There are currently several assessments, relating to eating and drinking and nutrition, that nursing staff undertake when a patient is admitted. These assessments are not all located in the same place and not as intuitive as they could be. We recognise that this is”

Source location
Response from York and Scarborough Teaching Hospitals NHS Foundation Trust
Page 1 · response
Published 15 October 2024
Open published response
24 Sep2024
Worcestershire
Concerns raised1
1. Failure to perform regular electrolyte testing when prescribing intravenous fluids
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Worcestershire Acute Hospitals NHS Trust
Stated actions 1
1. Worcestershire Acute Hospitals NHS Trust
  Include blood monitoring training in the core medical curriculum.
AI-generated summary

Kelly Marie STEVENS · 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

Kelly Stevens, who had profound learning and physical disabilities and received nutrition, hydration and medication via a PEG tube, was admitted to hospital on 28 December 2023. She suffered a seizure on 3 January 2024 caused by an excessively low, unrecognised sodium level, aspirated vomit, developed aspiration pneumonia and died in hospital later that night. Concerns included the absence of clear overall consultant responsibility, failure to monitor electrolytes and record fluid intake and output properly, and the copying of outdated care plans in her notes.

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 perform regular electrolyte testing when prescribing intravenous fluids
Wider context from the report
“2) No doctor providing care for Ms. Stevens followed the established principle that the prescription of intravenous fluids for a patient must be accompanied by regular testing of electrolytes. In Ms. Stevens’ case, this was particularly important because her baseline sodium level was low anyway, so the overprescription of fluids put her at greater risk of hyponatraemia; ”
Source location
Kelly Marie STEVENS · 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
Include blood monitoring training in the core medical curriculum.

Verbatim wording from the response
“2) Blood monitoring training is included as part of the core medical curriculum covered within medical training.”

Source location
Response from Worcestershire Acute Hospitals NHS
Page 2 · response
Published 25 September 2024
Open published response
27 Jun2024
Cornwall and Isles of Scilly
Concerns raised1
1. Errors in writing prescriptions for intravenous fluids
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Cornwall Partnership NHS Foundation Trust
Royal Cornwall Hospitals NHS Trust
Stated actions 1
1. Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
  Deliver human-factors and medication-error training through the revised LEAD programme for leaders, supervisors, and managers, with completion monitored electronically.
Respondent positions 1
1. Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
  Returning prescriptions to the original prescriber cannot safeguard against prescription errors outside normal hours because medical cover is limited.
  Unable to act
AI-generated summary

Paul Byron Holmes · 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

Paul Byron Holmes sustained fractured ribs and a fractured sternum in a road traffic collision on 4 April 2022, followed by hospitalisation, delirium, dehydration and declining health. He died at home on 29 May 2022 after returning for palliative care. Concerns included inadequate doctor-to-doctor handover and recording of the treatment plan during a hospital transfer, and a prescription error that delayed intravenous fluids.

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
Errors in writing prescriptions for intravenous fluids
Wider context from the report
“(4) An error in the writing out of a prescription for intravenous fluids at the Royal Cornwall meant that the administration of hydrating fluids at Liskeard Community Hospital was delayed. ”
Source location
Paul Byron Holmes · 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
Deliver human-factors and medication-error training through the revised LEAD programme for leaders, supervisors, and managers, with completion monitored electronically.

Verbatim wording from the response
“Whilst training regarding human factors and medication has previously been delivered on an ad hoc basis to all professional groups in the Trust, it is also now part of the revised LEAD programme aimed at all leaders, supervisors, and managers in RCHT. Specific reference to medication errors is made to ensure learning in personal awareness but also that the conditions we create for ourselves (and others) can contribute to slip and lapse errors which can be seen in tasks such as transcription and completing care related tasks.”

Source location
Royal Cornwall Hospitals NHS Trust
Page 4 · response
Published 28 June 2024
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
Returning prescriptions to the original prescriber cannot safeguard against prescription errors outside normal hours because medical cover is limited.

Verbatim wording from the response
“CFT recognise that an additional option in such circumstances would be for the receiving ward to return to the original prescriber to rectify any prescription issues. Upon review with ward managers, this course of action is routinely taken when prescription errors are detected in normal operating hours, however this is not a safeguard which would apply in the out-of-hours scenario which impacted Mr Holmes.”

Source location
Royal Cornwall Hospitals NHS Trust
Page 4 · response
Published 28 June 2024
Open published response
26 Apr2024
West Sussex, Brighton and Hove
Concerns raised1
1. Failure to recognise the risk of hyponatremia when giving intravenous fluids
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

NHS Surrey and Sussex Integrated Care Board
Nursing and Midwifery Council
Royal College of Obstetricians and Gynaecologists
Stated actions 4
1. NHS Surrey and Sussex Integrated Care Board
  Share NHS Sussex’s hyponatraemia and labour fluid-balance work with NHS England’s Regional Maternity Team to disseminate learning across Integrated Care Systems.
2. Nursing and Midwifery Council
  Investigate the concerns about the incident through fitness-to-practise processes to determine whether regulatory action is needed.
3. Nursing and Midwifery Council
  Share information about the doctor’s potential failure to recognise hyponatraemia with the General Medical Council.
1. Royal College of Obstetricians and Gynaecologists
  Approach NICE to suggest an addendum to the Intrapartum care guideline addressing hyponatraemia risks, fluid balance monitoring and related neonatal notification.
Respondent positions 2
1. Nursing and Midwifery Council
  The statutory remit does not extend to doctors, so the NMC cannot take regulatory action concerning the doctor involved.
  Outside remit
1. Nursing and Midwifery Council
  The GMC is responsible for considering whether further investigation or action is required concerning the doctor involved.
  Redirects responsibility
AI-generated summary

Orlando NOVA DAVIS · 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

Orlando Nova DAVIS suffered an irreversible brain injury after his mother developed unrecognised hyponatremia and seizures during labour, restricting oxygen before his birth. He died aged 14 days on 24 September 2021; the principal concerns were a lack of recognition and understanding of hyponatremia among midwives and clinicians, and inaccurate recording of fluid input and output despite additional fluids being given.

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 the risk of hyponatremia when giving intravenous fluids
Wider context from the report
“Orlando was caused an irreversible brain injury when his mother suffered a seizure having developed hyponatremia during her labour. The concern is that the midwifes (in the community and in the hosptial, who had cared for Orlando’s mother) were completely unaware of this potential condition developing in birthing women. In this case due to Orlando developing a tachicardia during labour Orlando’s mothers was actively encouraged to take in more fluid yet there was no accurate record kept of either input or output of fluid. Again when in hospital further fluids were given intravenously with no recognition of any potential risk of hyponatremia developing by the midwives or the Doctor on duty. ”
Source location
Orlando NOVA DAVIS · 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
Share NHS Sussex’s hyponatraemia and labour fluid-balance work with NHS England’s Regional Maternity Team to disseminate learning across Integrated Care Systems.

Verbatim wording from the response
“In order to enable the learning to be shared more widely with other Integrated Care Systems, our work on hyponatraemia and fluid balance in labour was shared with the Regional Maternity Team at NHS England in 2022, as part of the perinatal quality surveillance process, put in place following the Ockenden Review.”

Source location
Response from NHS Sussex
Page 3 · response
Published 9 May 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
Investigate the concerns about the incident through fitness-to-practise processes to determine whether regulatory action is needed.

Verbatim wording from the response
“1. We are carrying out Fitness to Practise (FtP) investigations and will take appropriate action to protect the public and uphold standards where we identify concerns relating to professionals on our register.”

Source location
Response from NMC
Page 1 · response
Published 9 May 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
Share information about the doctor’s potential failure to recognise hyponatraemia with the General Medical Council.

Verbatim wording from the response
“2. We have shared the PFD report with the General Medical Council (GMC) so they can take appropriate action which falls within their remit.”

Source location
Response from NMC
Page 1 · response
Published 9 May 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
Approach NICE to suggest an addendum to the Intrapartum care guideline addressing hyponatraemia risks, fluid balance monitoring and related neonatal notification.

Verbatim wording from the response
“The RCOG is committed to improving the standard of care provided for women by working collaboratively with all stakeholders and in response to this matter, the RCOG will approach NICE to suggest an addendum to their Intrapartum care guideline: NG235 along the following lines:”

Source location
Response from Royal College of Obstetricians and Gynaecologists
Page 2 · response
Published 9 May 2024
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 statutory remit does not extend to doctors, so the NMC cannot take regulatory action concerning the doctor involved.

Verbatim wording from the response
“The PFD report mentions that there was also a doctor on duty who failed to recognise the potential risk of hyponatraemia. Whilst our statutory remit does not extend to doctors, we have shared this information with the GMC in accordance with our fitness”

Source location
Response from NMC
Page 6 · response
Published 9 May 2024
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 GMC is responsible for considering whether further investigation or action is required concerning the doctor involved.

Verbatim wording from the response
“The PFD report mentions that there was also a doctor on duty who failed to recognise the potential risk of hyponatraemia. Whilst our statutory remit does not extend to doctors, we have shared this information with the GMC in accordance with our fitness”

Source location
Response from NMC
Page 6 · response
Published 9 May 2024
Open published response
6 Jun2023
Milton Keynes
Concerns raised1
1. Failure to correct and monitor prescribing clinicians' failure to sign off IV fluid prescriptions
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Milton Keynes University Hospital NHS Foundation Trust
Stated actions 2
1. Milton Keynes University Hospital NHS Foundation Trust
  Use quality-improvement methods to improve monitoring, review, antibiotics, fluid management, escalation and antimicrobial stewardship for sepsis.
2. Milton Keynes University Hospital NHS Foundation Trust
  Write to registered Emergency Department staff highlighting the case, referral-note review, electronic prescribing, fluid documentation, short-infusion orders and timely sepsis treatment.
AI-generated summary

Alexander Shone BLEWITT · 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

Alexander Shone Blewitt died at Milton Keynes University Hospital on 11 July 2022 after returning to the emergency department with faecal incontinence and abdominal pain, following an earlier visit where he had been referred from an urgent care centre. A possible acute abdomen was confirmed by CT, and he suffered a cardiac arrest before surgery. Concerns included inaccurate communication of important symptoms and treatment information, inadequate clinical recording, and the absence of reliable records of intravenous fluids administered in the emergency department.

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 correct and monitor prescribing clinicians' failure to sign off IV fluid prescriptions
Wider context from the report
“[5] The Incident Investigation Report which is in part designed to assist with learning from adverse events was of a generally poor standard. There was a failure to consider issues in detail; there was a failure to challenge the statements of clinicians where there were obvious contradictions between statements made and the medical record; there was a failure to put in place measures to correct and monitor prescribing clinicians failure to sign off on IV fluid prescriptions so that the contemporaneous record would be available for clinicians coming after them and they could see whether a patient had satisfactory or unsatisfactory fluid management. The only record in the case was a typed note by a junior doctor to the effect that it was thought Mr Blewitt had received 2 litres of fluid since arrival. ”
Source location
Alexander Shone BLEWITT · 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
Use quality-improvement methods to improve monitoring, review, antibiotics, fluid management, escalation and antimicrobial stewardship for sepsis.

Verbatim wording from the response
“The Sepsis QI Group will use quality improvement methodologies to provide assurance on current performance and to drive further improvement in areas contained within the relevant NICE quality statements, including:”

Source location
Response from Milton Keynes University Hospitals
Page 8 · response
Published 23 June 2023
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
Write to registered Emergency Department staff highlighting the case, referral-note review, electronic prescribing, fluid documentation, short-infusion orders and timely sepsis treatment.

Verbatim wording from the response
“The Chief Nurse and I will be writing to all registered staff in the ED to highlight the key elements of Mr Blewitt’s case, and to remind them of the issues referenced in this letter:”

Source location
Response from Milton Keynes University Hospitals
Page 8 · response
Published 23 June 2023
Open published response
18 Jan2022
Cornwall and Isles of Scilly
Concerns raised3
1. Failure to provide for careful reassessment after each IV fluid bolus
2. Failure to maintain aligned and current guidance on IV fluid bolus volumes for children presenting with shock
3. Unclear escalation thresholds for intensive care during fluid resuscitation
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

National Institute for Health and Care Excellence
Stated actions 2
1. National Institute for Health and Care Excellence
  Review relevant NICE guidance for alignment with the 2021 UK Resuscitation Council paediatric advanced life support guidance.
2. National Institute for Health and Care Excellence
  Review the 2021 UK Resuscitation Council guideline and consider whether CG84 and related NICE guidance need updating.
AI-generated summary

Coco Bradford · 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

Coco Bradford, a 6-year-old girl with autism, developed diarrhoea and vomiting, was diagnosed with haemolytic uraemic syndrome, deteriorated despite treatment and died in Bristol on 31 July 2017. The substantive concerns relate to the size and review of intravenous fluid boluses, when to escalate intensive care, and how clinicians should weigh antibiotic treatment when bacterial gastroenteritis and possible sepsis coexist because antibiotics may worsen haemolytic uraemic syndrome.

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 for careful reassessment after each IV fluid bolus
Wider context from the report
“1) In April 2009, NICE published CG 84 on Diarrhoea and Vomiting caused by gastroenteritis in Under 5s and management. Paragraph 1.3.3 deals with IV fluid management for patients presenting with shock. The guidance suggests rehydration with rapid IV infusion at 20mls/kg. The guidance is now a little dated and it is at odds with the Resuscitation Council UK Guidelines issued in 2021 which provide that for children and infants presenting with shock, fluid should be given in boluses of 10mls/kg – there is an emphasis on smaller boluses with careful re-assessment after each bolus to enable early identification of signs and symptoms of fluid overload. This was particularly relevant in Coco’s treatment where there was concern she may develop HUS with associated compromise of kidney function. As there appears now to be a move towards smaller boluses of fluid with more frequent review, it may be that you will also feel it appropriate to reconsider when to escalate care to colleagues in intensive care i.e. whether it should still be after two boluses or after a particular total amount of fluid. ”
Source location
Coco Bradford · 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 maintain aligned and current guidance on IV fluid bolus volumes for children presenting with shock
Wider context from the report
“1) In April 2009, NICE published CG 84 on Diarrhoea and Vomiting caused by gastroenteritis in Under 5s and management. Paragraph 1.3.3 deals with IV fluid management for patients presenting with shock. The guidance suggests rehydration with rapid IV infusion at 20mls/kg. The guidance is now a little dated and it is at odds with the Resuscitation Council UK Guidelines issued in 2021 which provide that for children and infants presenting with shock, fluid should be given in boluses of 10mls/kg – there is an emphasis on smaller boluses with careful re-assessment after each bolus to enable early identification of signs and symptoms of fluid overload. This was particularly relevant in Coco’s treatment where there was concern she may develop HUS with associated compromise of kidney function. As there appears now to be a move towards smaller boluses of fluid with more frequent review, it may be that you will also feel it appropriate to reconsider when to escalate care to colleagues in intensive care i.e. whether it should still be after two boluses or after a particular total amount of fluid. ”
Source location
Coco Bradford · 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
Unclear escalation thresholds for intensive care during fluid resuscitation
Wider context from the report
“1) In April 2009, NICE published CG 84 on Diarrhoea and Vomiting caused by gastroenteritis in Under 5s and management. Paragraph 1.3.3 deals with IV fluid management for patients presenting with shock. The guidance suggests rehydration with rapid IV infusion at 20mls/kg. The guidance is now a little dated and it is at odds with the Resuscitation Council UK Guidelines issued in 2021 which provide that for children and infants presenting with shock, fluid should be given in boluses of 10mls/kg – there is an emphasis on smaller boluses with careful re-assessment after each bolus to enable early identification of signs and symptoms of fluid overload. This was particularly relevant in Coco’s treatment where there was concern she may develop HUS with associated compromise of kidney function. As there appears now to be a move towards smaller boluses of fluid with more frequent review, it may be that you will also feel it appropriate to reconsider when to escalate care to colleagues in intensive care i.e. whether it should still be after two boluses or after a particular total amount of fluid. ”
Source location
Coco Bradford · 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
Review relevant NICE guidance for alignment with the 2021 UK Resuscitation Council paediatric advanced life support guidance.

Verbatim wording from the response
“Your report, which has been reviewed by our internal patient safety team and chief medical officer, states that the NICE guideline on the diagnosis and management of diarrhoea and vomiting caused by gastroenteritis in under 5s [CG84] is not in line with the UK Resuscitation Council’s 2021 guideline on paediatric advanced life support. Having reviewed the guidance, we agree that the volume of fluid bolus does not align and as a result of this being highlighted, we have also looked at our other guidance of relevance.”

Source location
2022-0012-Response-from-NICE_Published
Page 1 · response
Published 20 January 2022
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 2021 UK Resuscitation Council guideline and consider whether CG84 and related NICE guidance need updating.

Verbatim wording from the response
“In light of our initial review, your report has now been forwarded to our guideline surveillance team who will review the UK Resuscitation Council’s 2021 guideline and consider if CG84 and other related NICE guidance need to be updated.”

Source location
2022-0012-Response-from-NICE_Published
Page 1 · response
Published 20 January 2022
Open published response
17 May2018
Mid Kent and Medway
Concerns raised1
1. Failure to consider intravenous fluids after contrast CT before a prolonged nil-by-mouth procedure
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

BERNARD JOHN FAGG · 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

Bernard John Fagg was admitted to hospital with breathlessness and several suspected conditions, including heart failure, anaemia, fast atrial fibrillation and possible asbestos-related interstitial lung disease. After a contrast CT scan and an endoscopy, he developed acute kidney injury and died on 14 December 2017; clinicians attributed the death to contrast-induced nephropathy. The principal concern was whether intravenous fluids should have been considered because the endoscopy, requiring nil by mouth, took place shortly after the contrast CT scan.

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 consider intravenous fluids after contrast CT before a prolonged nil-by-mouth procedure
Wider context from the report
“Given the proximity of the endoscopy (which required nil by mouth) to the CT with contrast, the concern which arises is whether Mr Fagg should have been considered for and given intravenous fluids. The doctor who gave evidence said that having requested an endoscopy he would not necessarily have known when this procedure would take place. It is not suggested that the endoscopy should not have taken place but during the course of the evidence the doctor did raise the point that had he known that the endoscopy was to take place the day after the CT scan with contrast he may have considered intravenous fluids. The matter of concern is therefore whether a patient, even with normal renal function, should be considered for intravenous fluids in cases where they have had a CT scan with contrast and within a short time frame thereafter are required to undergo a procedure which will necessarily mean they will not be allowed to eat or drink for several hours. ”
Source location
BERNARD JOHN FAGG · Prevention of Future Deaths report
Page 2 · concerns
Open source report
27 Oct2014
Manchester South
Concerns raised1
1. Failure to monitor intravenous cannula connections and hydration delivery
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Tameside General Hospital
Stated actions 1
1. Tameside General Hospital
  Train nursing staff to secure cannulas and check for detachment or fluid loss during bedside attendance.
AI-generated summary

Agnes Mary Hannan · 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

Agnes Mary Hannan, who had autoimmune hepatitis with cirrhosis, attended Tameside General Hospital several times with severe abdominal pain before being admitted. She was diagnosed with Superior Mesenteric Vein Thrombosis causing bowel infarction and died on 21 September 2013. The report identified concerns about delayed diagnosis, inadequate monitoring and hydration, poor communication and handover, incomplete records, lack of multidisciplinary involvement, and insufficient communication with her family about her condition and end-of-life care.

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 monitor intravenous cannula connections and hydration delivery
Wider context from the report
“2. On one occasion whilst she was an in-patient, Mrs Hannan who was desperately ill and needing intra-venous hydration, was found to be lying in a soaking wet bed because the tube leading to her cannula had become dislodged and disconnected. The nursing staff had failed to notice this problem. The doctors in evidence, acknowledged that her lack of hydration would inevitably have worsened her already thrombosed veins. ”
Source location
Agnes Mary Hannan · 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
Train nursing staff to secure cannulas and check for detachment or fluid loss during bedside attendance.

Verbatim wording from the response
“Response The Trust’s nursing staff are trained to carefully insert and tape cannulas to the skin to minimise the risk of them becoming loose, disconnected or falling out. Unfortunately, despite taping them down cannulas do, on occasions, become loose, for example, if patients inadvertently dislodge them. If a cannula becomes dislodged patients may alert nursing staff so that it can be re-secured to prevent the loss of fluid. We appreciate that on occasions patients are not aware or are not well enough to alert nursing staff themselves. If that occurs our staff should become aware that there is a detached cannula and/or loss of fluid on next attending at the patient’s bedside.”

Source location
2014-0573-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 27 October 2014
Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Failure to target intravenous fluid management against patient response

Linked responses

Stated actions 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.3

Concerns raised2

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

Failure to monitor electrolytes before prescribing intravenous fluids

Linked response

Stated actions 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

Failure to assess and escalate refusal of intravenous fluids

Linked response

Stated actions 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 perform regular electrolyte testing when prescribing intravenous fluids

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Errors in writing prescriptions for intravenous fluids

Linked responses

Stated actions 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

Concerns raised1

Failure to recognise the risk of hyponatremia when giving intravenous fluids

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Stated actions 1

Respondent positions 3

Stated actions 4

Stated actions 2

Stated actions 1

Stated actions 1

Respondent positions 1

Stated actions 4

Respondent positions 2