Recurring concern
Unsafe intravenous fluid management
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Request correctionFirst reported 10 Mar 2014•Latest report 7 Apr 2025
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
- Individual concerns
- 14
- Date range
- 2014–2025
- Stated actions
- 18
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Deliver training and education on fluid management and maintaining fluid-balance charts.
Stated by North West Anglia NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Initial clinical management was appropriate because infection or sepsis was more likely than the much less likely diagnosis of cardiomyopathy.
Stated by Royal College of Emergency Medicine
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Position
Existing data show fluid management is not recurrent, while ward accreditation and matron audits provide ongoing monitoring and quality improvement.
Stated by NHS Central East Integrated Care Board -
Position
The Trust remains responsible for sharing emerging fluid-management themes or risks with the ICB through the monthly Integrated Quality Report.
Stated by NHS Central East Integrated Care Board
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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
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Issue an advisory notice reminding doctors to follow NICE guidance when prescribing intravenous fluids and monitoring electrolytes.
Stated by Worcestershire Acute Hospitals NHS Trust -
Action
Operate a working party to examine non-compliance with fluid-monitoring standards and address identified knowledge or skills gaps.
Stated by Worcestershire Acute Hospitals NHS Trust -
Action
Require all Trust doctors to undertake continuing professional development on electrolyte balance.
Stated by Worcestershire Acute Hospitals NHS Trust
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Action
Use electronic prescribing technology, where appropriate, to prompt doctors to consider blood-test results before prescribing intravenous fluids.
Stated by Worcestershire Acute Hospitals NHS Trust
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Concerns raised1
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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Introduce a Nucleus fluid assessment for all patients that prompts hydration monitoring according to clinical need.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust -
Action
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.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust
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Concerns raised1
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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Include blood monitoring training in the core medical curriculum.
Stated by Worcestershire Acute Hospitals NHS Trust
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Concerns raised1
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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Deliver human-factors and medication-error training through the revised LEAD programme for leaders, supervisors, and managers, with completion monitored electronically.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Returning prescriptions to the original prescriber cannot safeguard against prescription errors outside normal hours because medical cover is limited.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
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Concerns raised1
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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Share NHS Sussex’s hyponatraemia and labour fluid-balance work with NHS England’s Regional Maternity Team to disseminate learning across Integrated Care Systems.
Stated by NHS Surrey and Sussex Integrated Care Board -
Action
Investigate the concerns about the incident through fitness-to-practise processes to determine whether regulatory action is needed.
Stated by Nursing and Midwifery Council -
Action
Share information about the doctor’s potential failure to recognise hyponatraemia with the General Medical Council.
Stated by Nursing and Midwifery Council
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Action
Approach NICE to suggest an addendum to the Intrapartum care guideline addressing hyponatraemia risks, fluid balance monitoring and related neonatal notification.
Stated by Royal College of Obstetricians and Gynaecologists
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The statutory remit does not extend to doctors, so the NMC cannot take regulatory action concerning the doctor involved.
Stated by Nursing and Midwifery Council
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Position
The GMC is responsible for considering whether further investigation or action is required concerning the doctor involved.
Stated by Nursing and Midwifery Council
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Concerns raised1
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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Use quality-improvement methods to improve monitoring, review, antibiotics, fluid management, escalation and antimicrobial stewardship for sepsis.
Stated by Milton Keynes University Hospital NHS Foundation Trust -
Action
Write to registered Emergency Department staff highlighting the case, referral-note review, electronic prescribing, fluid documentation, short-infusion orders and timely sepsis treatment.
Stated by Milton Keynes University Hospital NHS Foundation Trust
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Concerns raised3
Failure to provide for careful reassessment after each IV fluid bolus
Failure to maintain aligned and current guidance on IV fluid bolus volumes for children presenting with shock
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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Review relevant NICE guidance for alignment with the 2021 UK Resuscitation Council paediatric advanced life support guidance.
Stated by National Institute for Health and Care Excellence -
Action
Review the 2021 UK Resuscitation Council guideline and consider whether CG84 and related NICE guidance need updating.
Stated by National Institute for Health and Care Excellence
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Concerns raised1
Failure to consider intravenous fluids after contrast CT before a prolonged nil-by-mouth procedure
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Train nursing staff to secure cannulas and check for detachment or fluid loss during bedside attendance.
Stated by Tameside General Hospital
Data last updated 7 September 2026