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.

Reports and published responses 11 reports

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

  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

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

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Data last updated 7 September 2026