Recurring concern
Unreliable management of patients’ fluid requirements
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Request correctionFirst reported 24 Sep 2014•Latest report 7 Apr 2025
What this concern includes
Includes failures in the patient fluid-management process, including determining and communicating fluid restrictions or requirements, prescribing and recording intravenous fluids, reviewing fluid charts and outcomes, and coordinating fluid decisions across responsible clinical staff.
Not included
- Excludes failures to provide adequate fluids where the asserted concern is solely omission or insufficiency of fluid provision rather than unreliable management of fluid requirements.
- Excludes electrolyte, renal or dialysis management concerns unless the report specifically identifies patient fluid requirements or fluid-management decisions as the unsafe condition.
- Excludes generic clinical documentation, communication or staffing deficiencies unless they directly impair management of a patient’s fluid requirements.
- Excludes unrelated medication, nutrition or hydration concerns where fluid requirements, restrictions or fluid treatment are not the bounded safety condition.
- Reports
- 11
- Individual concerns
- 11
- Date range
- 2014–2025
- Stated actions
- 16
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 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 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 raised1
Failure to provide for careful reassessment after each IV fluid bolus
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.
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 complete prescription and fluid balance charts for prescribed fluids
This report raised 7 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
Conduct regular Emergency Department spot audits and huddles to verify NEWS2 recording, prompt escalation and completion of fluid charts.
Stated by Blackpool Teaching Hospitals NHS Foundation Trust -
Action
Complete daily real-time Consistency in Care Audits reviewing NEWS2 and fluid-balance compliance and manage identified inconsistencies.
Stated by Blackpool Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure to clinically review fluid chart outcomes
This report raised 7 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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Inadequate discharge and pre-assessment process for subcutaneous fluid requirements
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.5
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Action
Review organisational pre-admission and admission policies and practices.
Stated by Hc-One Limited -
Action
Review the current admission process checklist.
Stated by Hc-One Limited -
Action
Include guidance requiring further information when pre-admission assessment occurred more than five days before admission, including medication and healthcare review updates.
Stated by Hc-One Limited
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Action
Cascade the revised admission practice across homes through the Homes’ Bulletin.
Stated by Hc-One Limited -
Action
Update the admission process checklist across all homes to reflect the revised practice.
Stated by Hc-One Limited
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Concerns raised1
Failure to reference fluid balance charts when prescribing further fluids
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
Distributed a learning bulletin on monitoring and completing fluid balance charts.
Stated by Tameside and Glossop Integrated Care NHS Foundation 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
Intravenous fluids were clinically appropriate based on clinical assessment and blood parameters, despite concerns they were prescribed without reference to the fluid balance chart.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
Failure to document and adhere to fluid restrictions
This report raised 18 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 integrated documentation for all clinical staff treating patients on Twineham ward.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Develop and deliver a Twineham ward training package on accurate documentation and the consequences of poor documentation.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Failure to record fluid intake and output
This report raised 24 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
Monitor documentation more closely and provide nurses with real-time feedback.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Review and condense Acute Medical Unit documentation into multidisciplinary paperwork that directs care and reduces duplication.
Stated by University Hospitals Sussex NHS Foundation Trust
Data last updated 7 September 2026