Recurring concern

Failure to reliably recognise and treat hypovolaemia

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First reported 13 Apr 2017•Latest report 13 Dec 2024

Definition

What this concern includes

Includes failures in the dedicated clinical process for recognising, assessing, escalating or treating hypovolaemia, including inadequate staff knowledge of early signs, delayed diagnosis, insufficient resuscitation and related training or guidance deficiencies.

Not included

Excludes generic bleeding, shock or deterioration concerns where hypovolaemia is not the material unsafe condition.
Excludes failures involving anticoagulation, haemorrhage or blood loss where no hypovolaemia recognition or treatment deficiency is identified.
Excludes failures occurring after hypovolaemia has been reliably recognised and appropriately treated.
Excludes generic training, staffing, communication or documentation deficiencies unless they directly impair recognition or treatment of hypovolaemia.

Reports: 3
Individual concerns: 4
Date range: 2017–2024
Stated actions: 6

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Cornwall Partnership NHS Foundation Trust1

Lancashire Teaching Hospitals NHS Foundation Trust1

Mid and South Essex NHS Foundation Trust1

Royal College of Obstetricians and Gynaecologists1

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.

13 Dec2024
Essex
Concerns raised1
1. Failure to recognise covert bleeding causing hypovolaemia
This report raised 15 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 5
1. Action
  Provide guidance on preventing and managing postpartum haemorrhage, including clinical assessment, monitoring, escalation and multidisciplinary response.
  Stated by Royal College of Obstetricians and GynaecologistsStated completed
2. Action
  Provide guidance on maternal collapse, including early-warning observation, systematic cause identification, ongoing assessment and concealed-haemorrhage diagnosis.
  Stated by Royal College of Obstetricians and GynaecologistsStated completed
3. Action
  Implement the OBS UK obstetric bleeding care bundle covering risk assessment, quantitative blood-loss measurement, escalation, and rapid clotting tests.
  Stated by Mid and South Essex NHS Foundation TrustStated in progress
1. Action
  Implement the national MEWS observation package and escalation policy, including trigger-team referral and mandatory maternity-inpatient use.
  Stated by Mid and South Essex NHS Foundation TrustStated completed
2. Action
  Embed deterioration recognition, concealed-bleeding assessment and escalation training in PROMPT, induction, local teaching, drills and written staff communications.
  Stated by Mid and South Essex NHS Foundation TrustStated completed
AI-generated summary

LAURA-JANE KIRSTEN NICOLE SEAMAN · 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

Laura-Jane Seaman died at Broomfield Hospital on 23 December 2022 following a massive intra-abdominal haemorrhage after a recent vaginal delivery, with subsequent disseminated intravascular coagulation. The principal concerns were failures to recognise and escalate maternal collapse and hypovolaemia, obtain and record vital signs and blood-test results, examine for covert bleeding, activate the major haemorrhage protocol, and provide appropriate senior review. The inquest concluded that her death was avoidable and contributed to by neglect.

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 recognise covert bleeding causing hypovolaemia
Wider context from the report
“(2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance with training and national guidance including PROMPT training, or the Royal College of Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and Puerperium (RCOG)Green-top Guideline No.56. The maternal collapse was categorised as a “Faint” by Trust staff and Laura-Jane was treated for potential dehydration (with no apparent risk factors) and administered medication that had only a transient effect. (3) The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful delivery and did not prompt a critical care review with a background of deranged vital signs. (4) There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised. The PROMPT training guidance contains illustrations by way of photographs to assist with the assessment of blood loss that focuses on per vaginal bleeding. Covert bleeding is referred to in the context of hypovolemia in a separate place on one line. Covert bleeding is not referred to in the Trust Drills & Skills Booklet. (5) Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger Consultant obstetric review, 2222 alert or referral to the critical care outreach team. ”
Source location
LAURA-JANE KIRSTEN NICOLE SEAMAN · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide guidance on preventing and managing postpartum haemorrhage, including clinical assessment, monitoring, escalation and multidisciplinary response.

Verbatim wording from the response
“The RCOG’s clinical guidance in this context includes the following:”

Source location
Response from Royal College of Obstetricians and Gynaecologists
Page 3 · response
Published 18 December 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide guidance on maternal collapse, including early-warning observation, systematic cause identification, ongoing assessment and concealed-haemorrhage diagnosis.

Verbatim wording from the response
“2. Maternal Collapse in Pregnancy and the Puerperium⁴ (Green-top Guideline No. 56). Clearly states that: “An obstetric modified early warning score chart should be used for all women undergoing”

Source location
Response from Royal College of Obstetricians and Gynaecologists
Page 3 · response
Published 18 December 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement the OBS UK obstetric bleeding care bundle covering risk assessment, quantitative blood-loss measurement, escalation, and rapid clotting tests.

Verbatim wording from the response
“Since August 2024, the maternity unit at Broomfield hospital has begun the implementation of a new obstetric bleeding strategy. The strategy works alongside current PROMPT recommendations of managing a postpartum haemorrhage already in place at the maternity unit.”

Source location
Response from Mid & South Essex NHS Trust
Page 4 · response
Published 18 December 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement the national MEWS observation package and escalation policy, including trigger-team referral and mandatory maternity-inpatient use.

Verbatim wording from the response
“The service identified these issues in the initial review of the incident. Since Laura-Jane’s death there has been an implementation of a new MEWS package with escalation policy. This includes the trigger response/medical emergency team once a score of 7 or above is reached.”

Source location
Response from Mid & South Essex NHS Trust
Page 6 · response
Published 18 December 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Embed deterioration recognition, concealed-bleeding assessment and escalation training in PROMPT, induction, local teaching, drills and written staff communications.

Verbatim wording from the response
“7) An ‘unwell woman’s’ simulation based on antepartum and postpartum haemorrhage including uterine rupture, abruption, and Vasa Previa, as well as a separate simulation on an anaphylaxis scenario was included in the 2023 PROMPT maternity training for all staff in addition to Human factors training, teamwork, situational awareness, and escalation.”

Source location
Response from Mid & South Essex NHS Trust
Page 8 · response
Published 18 December 2024
Open published response
20 Oct2023
Cornwall and Isles of Scilly
Concerns raised1
1. Insufficient training on the risks of hypovolaemia in anticoagulated patients
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 1
1. Action
  Amend the INR point-of-care-testing SOP and training video to cover anticoagulant-related bleeding complications and prompt observations after clinical deterioration.
  Stated by Cornwall Partnership NHS Foundation TrustStated planned
AI-generated summary

Valerie Ann Simmons · 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

Valerie Ann Simmons developed a large left-thigh haematoma after receiving Fragmin while receiving anticoagulation therapy, was later admitted to hospital, deteriorated and died on 11 January 2023. Concerns included the absence of recorded observations after a change in her presentation and the need for further training on the risks of hypovolaemia in an anticoagulated patient.

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
Insufficient training on the risks of hypovolaemia in anticoagulated patients
Wider context from the report
“Further training related to the risks of hypovolaemia in an anti-coagulated patient would be beneficial. ”
Source location
Valerie Ann Simmons · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Amend the INR point-of-care-testing SOP and training video to cover anticoagulant-related bleeding complications and prompt observations after clinical deterioration.

Verbatim wording from the response
“members of the community nursing team who have been specifically trained and assessed as competent in the use of the INR POCT device, and who can demonstrate an understanding of the role of INR testing including a basic interpretation of the INR result. Practitioners must demonstrate competence and be signed off before performing this role. However, on review of the SOP and training video, conducted in response to the Regulation 28 report, we have identified that it does not include awareness on the tendency of patients taking anticoagulants to have bleeding complications such as haematomas, or how to manage the side effects/consequences for example hypovolaemia. (A haematoma is a collection of blood which is located outside the blood vessels. They can be found under the skin within a soft tissue and display as a purple-coloured bruise.”

Source location
Response from Cornwall Partnership NHS Foundation Trust
Page 3 · response
Published 31 October 2023
Open published response
13 Apr2017
Preston and West Lancashire
Concerns raised2
1. Failure to provide adequate and timely resuscitation for hypovolaemia
2. Lack of knowledge and recognition of early signs of hypovolaemia
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 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.
AI-generated summary

Michael John NEWELL · 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

Michael John Newell died following an admission involving haemorrhage, decompensated liver failure and associated coagulopathy. Concerns included a lack of awareness among emergency and surgical staff of the significance of his liver failure, inadequate recognition and treatment of hypovolaemia, lack of consultant ENT input, weaknesses in the mortality review process, and nursing documentation and management issues.

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 provide adequate and timely resuscitation for hypovolaemia
Wider context from the report
“(2) the junior ENT surgeons and neurosurgeons showed a startling lack of knowledge of the early signs of hypovolaemia and, if any did realise, made no attempt to treat Mr Newell adequately. Whilst this PFD report is primarily sent with regard to the death of Mr Newell, this has been a feature over a number of years of other cases where hypovolaemia was not appropriately diagnosed and late resuscitation ensued. ”
Source location
Michael John NEWELL · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of knowledge and recognition of early signs of hypovolaemia
Wider context from the report
“(2) the junior ENT surgeons and neurosurgeons showed a startling lack of knowledge of the early signs of hypovolaemia and, if any did realise, made no attempt to treat Mr Newell adequately. Whilst this PFD report is primarily sent with regard to the death of Mr Newell, this has been a feature over a number of years of other cases where hypovolaemia was not appropriately diagnosed and late resuscitation ensued. ”
Source location
Michael John NEWELL · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to recognise covert bleeding causing hypovolaemia

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

Concerns raised1

Insufficient training on the risks of hypovolaemia in anticoagulated patients

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

Concerns raised2

Failure to provide adequate and timely resuscitation for hypovolaemia

Lack of knowledge and recognition of early signs of hypovolaemia

Actions described in response 5

Actions described in response 1