Recurring concern

Unsafe intravenous fluid management

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First reported 10 Mar 2014•Latest report 7 Apr 2025

Definition

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.

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.
Reports
11

Distinct published reports

Individual concerns
14

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
18

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.

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

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. Manchester South

    AI-generated summary

    Afifa Qaisar · 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

    Afifa Qaisar was admitted to Tameside General Hospital on 23 June 2013 with collapse and confusion, initially diagnosed as meningitis with sepsis, and died at 20.30 hours the same day. Concerns included uncertainty about whether drugs recorded as given had actually been administered, unavailability of required resuscitation equipment, failure to notify the RMO, delays in platelet and Hb support, an inappropriate response to an apparently non-running saline infusion, and failure to commence fluid balance monitoring or catheterisation.

    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 appropriately assess and manage a non-running saline infusion

    Wider context from the report

    “5. When the husband of the deceased drew to the attention of the staff that the saline infusion appeared not to be ‘running’ so he was told by the nurse to “hold her arm straight” to enable it to do so. He and I, and the Ward manager, felt that this was entirely inappropriate. ”

    Source location

    Afifa Qaisar · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026