First reported 11 Jul 2014•Latest report 30 Jan 2026
Definition
What this concern includes
Includes failures of renal monitoring arrangements, including required blood tests, imaging, fluid monitoring, responsibility allocation, communication, follow-up and escalation, where these controls are specifically intended to monitor patients with renal disease or renal failure.
Not included
Excludes generic diagnostic testing, clinical monitoring or care-coordination failures that are not specifically tied to renal monitoring.
Excludes treatment or fluid-provision failures where no deficient renal-monitoring control is identified.
Excludes failures concerning other organ systems unless the report explicitly connects them to the same renal-monitoring process.
Excludes generic governance, staffing or communication deficiencies unless they directly undermine reliable renal monitoring.
Reports
7
Distinct published reports
Individual concerns
7
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
24
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
Aneurin Bevan University LHB1
Cann House Care Home1
Faculty of Intensive Care Medicine1
Frimley Health NHS Foundation Trust1
Greater Manchester Health and Social Care Partnership1
Medicines and Healthcare products Regulatory Agency1
NHS Greater Manchester Integrated Care Board1
Northern Care Alliance NHS Foundation Trust1
Pennine Care NHS Foundation Trust1
Premiere Health Limited1
Royal College of Anaesthetists1
Royal Surrey County Hospital1
St Chads Medical Practice1
The Intensive Care Society1
NHS trust3
Ministerial department2
Healthcare site1
Health professional body1
Health-system partnership1
Integrated care board1
Local health board1
Medicines and medical devices regulator1
Multi-service care provider1
Nursing home1
Private limited company1
Registered charity1
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.
Devon, Plymouth and Torbay
Concerns raised1
Failure to carry out regular blood tests
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Enforce the hospital discharge and clinical follow-up procedure, including review, action logging, GP confirmation and management audit.
Stated by Premiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Gwent
Concerns raised1
Failure to monitor fluid balance
Responses linked to these concerns
Each 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.11
Action
Complete the review of Health Board documentation, monitoring tools and relevant national guidelines to establish an evidence base for best practice.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 3 February 2025.
Action
Establish and operate a multidisciplinary Fluid Balance Task and Finish Group with defined improvement objectives.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 3 February 2025.
Action
Initiate a surgical-ward fluid-balance monitoring pilot incorporating staff education, information boards, data sharing and auditing.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 3 February 2025.
Action
Standardise fluid-balance monitoring documentation across the organisation.
Stated by Aneurin Bevan University LHBStatus unclearThe respondent did not make the status of this action clear when they made their response on 3 February 2025.
Action
Explore using a digital observation platform to record fluid balance.
Stated by Aneurin Bevan University LHBStatus unclearThe respondent did not make the status of this action clear when they made their response on 3 February 2025.
Action
Develop a multidisciplinary fluid-balance standard operating procedure.
Stated by Aneurin Bevan University LHBStatus unclearThe respondent did not make the status of this action clear when they made their response on 3 February 2025.
Action
Disseminate expected fluid-balance monitoring standards through feedback sessions, posters, emails, ward meetings and learning events.
Stated by Aneurin Bevan University LHBStatus unclearThe respondent did not make the status of this action clear when they made their response on 3 February 2025.
Action
Deliver strengthened multidisciplinary education and training on fluid-balance roles, responsibilities and best practice.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 3 February 2025.
Action
Engage senior medical staff to support education and establish clinical expectations for fluid-balance monitoring.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 3 February 2025.
Action
Incorporate Medical Examiner and Quality Safety Learning Forum learning into the fluid-balance improvement plan.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 3 February 2025.
Action
Use the AMAT tool to standardise fluid-balance compliance audits, conduct audits through ward accreditation and report results to the Nutrition and Hydration Committee.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 3 February 2025.
Manchester South
Concerns raised1
Insufficient monitoring of kidney function to avoid opiate toxicity
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Lack of understanding and recognition of kidney-function monitoring alongside prescribing of pain medication
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester North
Concerns raised1
Failure to ensure required blood tests for individuals under specialist secondary care for renal failure
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 concerns
Each 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.12
Action
Modify patient letters to explain blood-test arrangements clearly and provide an SRFT contact for monitoring difficulties.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Ask GPs before ESA treatment whether they can monitor bloods, record responses electronically, agree monitoring plans, and follow up non-responses.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Assume responsibility for taking bloods until the GP responds, ensuring clinically necessary ESA treatment can begin.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Develop and implement a standard operating policy covering ESA blood-monitoring arrangements, outstanding responses, and negative responses.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Update the electronic record to track ESA blood results due, missing results requiring follow-up, and the latest haemoglobin results.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Allocate prescriber job-plan time for ESA monitoring and prescribing.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Write to existing ESA patients to identify difficulties accessing monitoring and manage identified difficulties under the agreed policy.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Explore a Greater Manchester commissioned shared-care protocol for ESA monitoring through CCGs and the Medicines Management Group.
Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 June 2019.
Action
Establish an operating procedure requiring direct GP communication and a provider response before confirming monitoring-dependent treatment plans.
Stated by NHS Oldham CCGStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Describe the shared-care model in a business case for consideration by the Greater Manchester Medicines Management Group and local commissioners.
Stated by NHS Oldham CCGStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Identify patients receiving or potentially requiring shared-care ESA pathways and write to GP practices to promote robust monitoring.
Stated by NHS Oldham CCGStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Notify the CCG that the Practice was asked to monitor a red-status medication and report the associated significant event.
Stated by St Chads Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The SPoA and District Nursing service followed due process and acted appropriately on the referral based on the information available.
Stated by Pennine Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The community nursing service was commissioned to provide phlebotomy only for housebound patients, and this patient was not housebound.
Stated by Pennine Care NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Practice should not accept responsibility for monitoring EPO; the CCG will liaise directly with the Trust and medicines management.
Stated by St Chads Medical PracticeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Norfolk
Concerns raised1
Failure to carry out daily blood tests to monitor haemoglobin levels
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 concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Medical plans may appropriately change without formally addressing each earlier entry unless there is a serious reason to question the initial opinion.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised1
Inadequate assessment of renal stone size and hydronephrosis
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures of renal monitoring arrangements, including required blood tests, imaging, fluid monitoring, responsibility allocation, communication, follow-up and escalation, where these controls are specifically intended to monitor patients with renal disease or renal failure.
