Recurring concern

Unreliable recording of fluid balance information

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First reported 6 Nov 2013•Latest report 22 Dec 2025

Definition

What this concern includes

Includes failures of the dedicated fluid-balance recording process, including records of intravenous fluids, fluid intake and output, and food or fluid offers and consumption, where the recording deficiency impairs reliable assessment of fluid status.

Not included

Excludes failures to administer prescribed fluids when the recording process itself is not deficient.
Excludes general poor maintenance of clinical or nursing records unrelated to fluid balance.
Excludes failures in fluid-balance assessment, escalation or treatment decisions unless they also involve unreliable fluid-balance recording.

Reports: 46
Individual concerns: 50
Date range: 2013–2025
Stated actions: 87

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.

Department of Health and Social Care6

University Hospitals Sussex NHS Foundation Trust4

Blackpool Teaching Hospitals NHS Foundation Trust3

Care Quality Commission3

NHS England3

Ashford and St Peter'S Hospitals NHS Foundation Trust2

General Medical Council2

Greater Manchester Mental Health NHS Foundation Trust2

Pennine Acute Hospitals NHS Trust2

Royal College of Obstetricians and Gynaecologists2

Stockport NHS Foundation Trust2

Academy of Medical Royal Colleges1

Amberley Hall Care Home1

Athena Care Homes (UK) Limited1

Barking, Havering and Redbridge University Hospitals NHS Trust1

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.

24 Jul2023
Avon
Concerns raised1
1. Poor completion of fluid balance charts
This report raised 14 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

Alan Christopher NIPPARD · 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

Alan Christopher Nippard was admitted to hospital after a fall and developed a sacral pressure sore during his admission, followed by infection and deterioration. He died on 6 July 2022 after surgery was considered unsuitable. The report identified concerns that the pressure sore was preventable and that basic nursing care, including risk assessment, skin care, repositioning and personal care, was not provided adequately.

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
Poor completion of fluid balance charts
Wider context from the report
“I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with. There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking. It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired. That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight. I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including: • That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly. • On the MAU he did not have his risk assessment done within 6 hrs as it should have been. • It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress. • Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay. • Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved. • The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed. • Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t. • On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation • Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all. • It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been. • When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly. • It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved • There was no evidence of the use of 2 sliding sheets to assist with moving him. • On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all. • Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable. • Fluid balance charts were poorly completed. • He wasn’t weighed which would have assisted with managing his oedema. • Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care. I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team. ”
Source location
Alan Christopher NIPPARD · Prevention of Future Deaths report
Page 4 · concerns
Open source report
6 Jun2023
Milton Keynes
Concerns raised1
1. Lack of effective, reliable recording of intravenous fluids administered in the emergency department
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Implement a short-infusion electronic fluid order that remains visible until administration or discharge.
  Stated by Milton Keynes University Hospital NHS Foundation TrustStated completed
2. 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 TrustStated planned
Respondent positions 1
1. Position
  The electronic prescribing expiry issue was not relevant to the patient's case, although fluid administration documentation was poor.
  Stated by Milton Keynes University Hospital NHS Foundation TrustDisputes the concern
AI-generated summary

Alexander Shone BLEWITT · 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

Alexander Shone Blewitt died at Milton Keynes University Hospital on 11 July 2022 after returning to the emergency department with faecal incontinence and abdominal pain, following an earlier visit where he had been referred from an urgent care centre. A possible acute abdomen was confirmed by CT, and he suffered a cardiac arrest before surgery. Concerns included inaccurate communication of important symptoms and treatment information, inadequate clinical recording, and the absence of reliable records of intravenous fluids administered in the emergency department.

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
Lack of effective, reliable recording of intravenous fluids administered in the emergency department
Wider context from the report
“[1] At the time of Mr Blewitt's death there was no effective, reliable recording of intravenous fluids administered to patients in the emergency department. That in my view has potential to represent a threat to the safety and lives of patients suffering with a wide variety of different conditions. The author of the SI report who attended to give evidence did not, at the time of request 8 months later, was unable to demonstrate that the Trust had remedied that. ”
Source location
Alexander Shone BLEWITT · 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
Implement a short-infusion electronic fluid order that remains visible until administration or discharge.

Verbatim wording from the response
“This issue was raised with Oracle Cerner and we developed a distinct ‘short infusion’ order. In this scenario, the prescription remains a planned administration and does not ‘grey out’ on the chart at the expected time of completion. The ‘short infusion’ order remains visible as due until it is administered, or when the patient is discharged from the clinical encounter. It does not expire at a timepoint related to the time of prescription and/or the calculated time of completion of administration. It has been specifically designed for use when prescribing fluids for infusion over a short duration (i.e., an hour or less).”

Source location
Response from Milton Keynes University Hospitals
Page 3 · response
Published 23 June 2023
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
Write to registered Emergency Department staff highlighting the case, referral-note review, electronic prescribing, fluid documentation, short-infusion orders and timely sepsis treatment.

Verbatim wording from the response
“The Chief Nurse and I will be writing to all registered staff in the ED to highlight the key elements of Mr Blewitt’s case, and to remind them of the issues referenced in this letter:”

Source location
Response from Milton Keynes University Hospitals
Page 8 · response
Published 23 June 2023
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The electronic prescribing expiry issue was not relevant to the patient's case, although fluid administration documentation was poor.

Verbatim wording from the response
“In Mr Blewitt’s case, documentation around fluid administration is poor but it does not seem that this specific eCare related issue – which I think was introduced into evidence at the Inquest - was relevant.”

Source location
Response from Milton Keynes University Hospitals
Page 3 · response
Published 23 June 2023
Open published response
9 Feb2023
East London
Concerns raised2
1. Failure to put fluid balance charts in place
2. Poor maintenance of clinical records of fluid administration
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 5
1. Action
  Conduct and continue unannounced cross-site fluid-management audits on every COTE ward, monitoring Careflow Vitals recording and appropriate follow-up.
  Stated by BHRUTStated in progress
2. Action
  Conduct peer fluid-monitoring audits between COTE wards and share results through governance meetings and daily huddles.
  Stated by BHRUTStated in progress
3. Action
  Provide nursing staff with Careflow Vitals training and one-to-one fluid-monitoring support.
  Stated by BHRUTStated completed
1. Action
  Train medical staff to access fluid balances in Careflow Vitals and discontinue completion of paper fluid charts.
  Stated by BHRUTStated completed
2. Action
  Carry out a clinical safety assessment to identify and mitigate hazards affecting entry or viewing of fluid-balance data.
  Stated by BHRUTStated planned
AI-generated summary

George Frederick Kearsey · 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

George Frederick Kearsey sustained injuries in a fall at home, was admitted to hospital, developed aspiration pneumonia, and died on the evening of 8 June 2022. Concerns included inconsistent administration of IV fluids, missing fluid balance charts, poorly maintained clinical records, and inadequate review of fluid monitoring during consultant-led ward rounds.

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 put fluid balance charts in place
Wider context from the report
“2. Contrary to Trust policy, fluid balance charts were not put in place to assess Mr Kearsey’s fluid intake and output. ”
Source location
George Frederick Kearsey · Prevention of Future Deaths report
Page 2 · 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
Poor maintenance of clinical records of fluid administration
Wider context from the report
“3. Clinical records were poorly maintained, resulting in an unclear picture of fluid administration. ”
Source location
George Frederick Kearsey · 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
Conduct and continue unannounced cross-site fluid-management audits on every COTE ward, monitoring Careflow Vitals recording and appropriate follow-up.

Verbatim wording from the response
“• Cross site audits have been completed on COTE (Care of the Elderly) wards on a random basis to understand a cross section of compliance with fluid management with no notice given to the ward in advance of the audit. The audits capture patients who are on fluid restriction, patients requiring oral and intravenous hydration, parenteral nutrition and output monitoring, whether the intake and output is entered on Careflow Vitals and appropriate action taken as necessary. The audits were completed by senior nursing teams (Matrons, Ward Managers, Practice Development Nurses).”

Source location
Response from Barking, Havering and Redbridge University Hospitals
Page 1 · response
Published 24 February 2023
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
Conduct peer fluid-monitoring audits between COTE wards and share results through governance meetings and daily huddles.

Verbatim wording from the response
“• Peer audits are being undertaken - The first phase of the audits has been completed. The nursing staff on all wards have been informed of the expectation for fluid monitoring and recording this on Careflow Vitals. We have also introduced peer audits where ward teams will conduct random audits on other COTE wards for the next 6 months. The format of these audits will mirror those conducted by the wards. The feedback from these audits will be shared with the matron and ward manager of that area and relevant action taken, if required. An example is if a patient is on fluid restriction and their fluid intake has not been recorded on careflow vitals. This can have an adverse effect on the patient’s treatment. The ward manager will discuss the importance of fluid management and monitoring with staff.”

Source location
Response from Barking, Havering and Redbridge University Hospitals
Page 2 · response
Published 24 February 2023
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 nursing staff with Careflow Vitals training and one-to-one fluid-monitoring support.

Verbatim wording from the response
“• Nursing staff have received additional training on Careflow vitals to reinforce the importance of staff compliance with the Trust policy on the completion of fluid monitoring. In addition, nursing staff have had 1:1 sessions with matrons and practice development nurses. Since the implementation of the audits, an improvement has been noted in fluid balance monitoring. For example, on 15 February 2023, Clementine A only scored 70% compliance. The gaps were discussed and addressed immediately with the nursing teams. This improved the compliance on Clementine A, with audits now showing 100% compliance.”

Source location
Response from Barking, Havering and Redbridge University Hospitals
Page 2 · response
Published 24 February 2023
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
Train medical staff to access fluid balances in Careflow Vitals and discontinue completion of paper fluid charts.

Verbatim wording from the response
“• We identified that some medical staff were not familiar with using Careflow Vitals to access patients’ fluid balance. Face to face training, by the Careflow team has now been provided for all medical staff, to ensure they are all aware of how to access the fluid balance on Careflow Vitals. Medical staff were all made aware that paper fluid charts will not be completed in the future.”

Source location
Response from Barking, Havering and Redbridge University Hospitals
Page 2 · response
Published 24 February 2023
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
Carry out a clinical safety assessment to identify and mitigate hazards affecting entry or viewing of fluid-balance data.

Verbatim wording from the response
“In addition to the above a Clinical Safety Assessment is to be carried out by the end of April 2023. The purpose of the assessment is to identify any hazards, risks or issues to mitigate any issues of not being able to enter data or view fluid balance records. Thirteen staff completed the clinical safety (CS) officer training on the 29th /30th March. The CS role is in the recruitment process and will be interviewed for on the 18th April 2023.”

Source location
Response from Barking, Havering and Redbridge University Hospitals
Page 3 · response
Published 24 February 2023
Open published response
28 Nov2022
Norfolk
Concerns raised2
1. Inaccurate recording of food intake
2. Failure to record fluid intake directly by the estimating staff
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 1
1. Action
  Operate a hydration-monitoring system using first-four-week fluid charts, shift-based hydration trolleys, millilitre recording and daily senior review of charts and electronic records.
  Stated by Runwood Homes PLCStated completed
AI-generated summary

Janice HOPPER · 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

Janice HOPPER was discharged from hospital to a care home on 31 December 2021, became unwell in January 2022, was admitted to hospital, and died on 12 February 2022. Concerns included inaccurate and inadequately reviewed care plans, failures to monitor blood glucose, food and fluid intake, and the administration of Morphine Sulphate as a matter of course despite instructions that it was to be given only as required. The inquest recorded the medical cause of death as Alzheimer's Dementia, Chronic Kidney Disease and Type 2 Diabetes Mellitus, with a conclusion of natural causes.

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
Inaccurate recording of food intake
Wider context from the report
“9. There were concerns about Mrs Hopper's food intake. It is not clear from the evidence that the amount stated in the records as being consumed was accurate. For instance, on several occasions she was noted to have consumed large amounts of fluid in one go and to have eaten more than one meal within a short space of time. ”
Source location
Janice HOPPER · Prevention of Future Deaths report
Page 2 · 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
Failure to record fluid intake directly by the estimating staff
Wider context from the report
“8. The amount of fluid intake was not always recorded in the notes by the staff who had estimated the amount consumed but relayed to another member of staff who would complete the records. ”
Source location
Janice HOPPER · 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
Operate a hydration-monitoring system using first-four-week fluid charts, shift-based hydration trolleys, millilitre recording and daily senior review of charts and electronic records.

Verbatim wording from the response
“All residents’ care plans are developed with the individual, information gained from the residents’ pre admission assessment and information gained from the resident and their family allows us to gain information regarding what their fluid intake has been like and also through fluid charts for the first four weeks, allows us to monitor fluid intake. Hydration trolleys are in effect at the home, one each shift one person is allocated to be responsible for ensuring that residents’ fluid intake is monitored and documented accurately. This was discussed at the care plan training and how to accurately record fluid intake. All staff are required to ensure that they record intake in millilitres, “mls” in all entries so that the electronic care record system automatically picks up the intake and calculates it.”

Source location
Response from Runwood Homes
Page 2 · response
Published 1 December 2022
Open published response
15 Nov2022
Berkshire
Concerns raised1
1. Failure to maintain complete records of fluid provision and pad status
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.
Respondent positions 1
1. Position
  The provider has taken sufficient action to mitigate risks and prevent future deaths.
  Stated by Care Quality CommissionExisting arrangements considered sufficient
AI-generated summary

Frederick Robert Peter King · 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

Frederick Robert Peter King was a resident at Birchwood Care Home and died in hospital on 9 September 2021 from an acute kidney injury caused by dehydration, with frailty and vascular dementia contributing to his death. The concerns included inadequate fluid provision, incomplete care records, and the absence of a care-home manager on the ground in the three days before his death.

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 maintain complete records of fluid provision and pad status
Wider context from the report
“(2) Inadequate record keeping in the Birchwood Care made it difficult to obtain the relevant records for the Inquest and the records obtained were incomplete for example in terms of what recording timings of fluid provision, whether pads were wet/dry and also family concerns regarding health were not recorded and conveyed. ”
Source location
Frederick Robert Peter King · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The provider has taken sufficient action to mitigate risks and prevent future deaths.

Verbatim wording from the response
“We sent an urgent letter to the provider West Berkshire Council to confirm CQC had received the regulation 28 report and asked them to set out in writing evidence of the actions they had taken to date following this death and any additional action they intended to take in response to the prevention of future death report. We received a detailed response from the provider. We are satisfied the provider has taken sufficient action according to section 6 of the regulation 28 report to mitigate risks to people and prevent future deaths.”

Source location
Response from Care Quality Commission
Page 2 · response
Published 21 November 2022
Open published response
14 Sep2022
Lincolnshire
Concerns raised1
1. Failure to record fluid intake accurately
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 4
1. Action
  Maintain ongoing staff training on nutrition, hydration, and responding to declining food or fluid intake.
  Stated by TanglewoodStated in progress
2. Action
  Review and amend the Nutrition and Hydration policy to cover intake recording, refusals, fluid targets, and discussions with clinicians and families.
  Stated by TanglewoodStated completed
3. Action
  Embed admission safeguards requiring risk assessments, daily charts, documented communications, timely referrals, and updates to residents and representatives.
  Stated by TanglewoodStated in progress
1. Action
  Continue face-to-face staff training on care documentation and recording offered or declined nutrition and fluids.
  Stated by TanglewoodStated in progress
Respondent positions 1
1. Position
  Staff cannot force residents to take food or fluids when they refuse, but must record the refusal and intake.
  Stated by TanglewoodUnable to act
AI-generated summary

Lilian SHEARING · 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

Lilian SHEARING died in Lincoln County Hospital on 29 September 2019 after admission for unrelated medical treatment. Before her hospital admission, poor fluid intake was recorded at her care home, but no risk assessment was undertaken and omissions were made from the fluid intake chart; her intake was later estimated to have been approximately 25% of the expected level due to dehydration.

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 record fluid intake accurately
Wider context from the report
“Upon admission on 11th July 2019 to your care home it was recorded at handover the deceased had a poor fluid intake. Despite this no risk assessment was undertaken. Omissions were also made from the fluid intake chart. It was conceded at Inquest today by your regional manager that the deceased's fluid intake was approximately 25% of where it should have been before her admission to hospital on 23rd August 2019 due to dehydration. Policies/assessments were clearly not in place to cover this eventuality. What are your current policies re risk assessments for fluid and nutritional intake? ”
Source location
Lilian SHEARING · Prevention of Future Deaths report
Page 1 · 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
Maintain ongoing staff training on nutrition, hydration, and responding to declining food or fluid intake.

Verbatim wording from the response
“Training It is three years since Mrs LS death and the monitoring and auditing processes within all Tanglewood homes has been enhanced significantly. Throughout the pandemic, work has been ongoing to continue to provide essential training. A new platform for e-learning was introduced which enabled team members, both newly employed and established, to access ongoing training throughout this period. There has been a continued focus on the importance of nutrition and hydration and how we support residents in all stages of their later life and what we can do in the event of the individual declining adequate nutritional and fluid intake required to sustain life. A care plan manager has been employed to oversee the care plans and content in all homes ensuring the standard of documentation is consistent, this person also provides training to all care teams to ensure the process is understood.”

Source location
Response from Tanglewood Cloverleaf Care Home
Page 1 · response
Published 5 October 2022
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
Review and amend the Nutrition and Hydration policy to cover intake recording, refusals, fluid targets, and discussions with clinicians and families.

Verbatim wording from the response
“Policy & Procedure We have reviewed the content of the Nutrition & Hydration policy and amended the content to include current practice of monitoring and recording all intake (see appendix 1), how we support the resident who may be reluctant to accept food and fluids especially at end of life, and the importance of recording if a resident declines assistance or intervention. What we do if a residents daily fluid target appears excessive and is not consistently achieved over a 7-day period and how we manage and record the discussions with the GP and family members in relation to this.”

Source location
Response from Tanglewood Cloverleaf Care Home
Page 1 · response
Published 5 October 2022
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 admission safeguards requiring risk assessments, daily charts, documented communications, timely referrals, and updates to residents and representatives.

Verbatim wording from the response
“• Ensure that any risk assessments required are completed to ensure minimal risk to the person”

Source location
Response from Tanglewood Cloverleaf Care Home
Page 2 · response
Published 5 October 2022
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
Continue face-to-face staff training on care documentation and recording offered or declined nutrition and fluids.

Verbatim wording from the response
“• Ongoing face-to-face staff training within the homes to embed the importance of maintaining records and documentation to provide evidence of care provided”

Source location
Response from Tanglewood Cloverleaf Care Home
Page 2 · response
Published 5 October 2022
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Staff cannot force residents to take food or fluids when they refuse, but must record the refusal and intake.

Verbatim wording from the response
“• Ongoing staff training within the homes to ensure that all nutritional and fluid intake is recorded even if declined as we are unable to force residents to take food & fluids if they refuse”

Source location
Response from Tanglewood Cloverleaf Care Home
Page 2 · response
Published 5 October 2022
Open published response
28 Jan2022
West Yorkshire Eastern
Concerns raised2
1. Failure of managers to detect inadequate monitoring records
2. Inadequate contemporaneous records of fluid intake and output
This report raised 5 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 4
1. Action
  Deliver catheter-care refresher training and shared learning on fluid-intake recording and alternative catheter access routes.
  Stated by Exemplar Health CareStated completed
2. Action
  Digitise EQA governance and establish team-leader accountability, daily management reviews, clinical walkarounds, take-twenty meetings and electronic quality-assurance tracking.
  Stated by Exemplar Health CareStated completed
3. Action
  Implement monthly audits of supplementary and care files, with findings discussed with unit managers.
  Stated by Exemplar Health CareStated completed
1. Action
  Deliver workshops and coaching on creating, implementing and monitoring unambiguous care plans and comprehensive records across all service users.
  Stated by Exemplar Health CareStated completed
Respondent positions 1
1. Position
  Existing management oversight, quality assurance and governance processes are considered sufficient to ensure records are kept, retained and reviewed for trends.
  Stated by Exemplar Health CareExisting arrangements considered sufficient
AI-generated summary

Mark Anthony Athias · 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

Mark Anthony Athias had multiple physical and mental health issues, including recurring urinary infections and problems with a long-term catheter. After difficulties with his catheter on 2 July 2021, he was admitted to hospital, where his condition deteriorated and he died on 6 July 2021. Concerns included a lack of sterile replacement catheters, inadequate monitoring records, and a missing handover record, with risks arising from deficient record keeping.

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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 of managers to detect inadequate monitoring records
Wider context from the report
“2. The catheter care plan had identified the need for his fluid intake and output to be monitored. The contemporaneous records kept were, however, inadequate. This hindered any assessment of his urinary problems. The managers in the nursing home had not noticed the inadequacy of such records. ”
Source location
Mark Anthony Athias · 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
Inadequate contemporaneous records of fluid intake and output
Wider context from the report
“2. The catheter care plan had identified the need for his fluid intake and output to be monitored. The contemporaneous records kept were, however, inadequate. This hindered any assessment of his urinary problems. The managers in the nursing home had not noticed the inadequacy of such records. ”
Source location
Mark Anthony Athias · Prevention of Future Deaths report
Page 1 · 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
Deliver catheter-care refresher training and shared learning on fluid-intake recording and alternative catheter access routes.

Verbatim wording from the response
“Copperfields delivered shared learning with the nursing staff following Mr Athias' death which highlighted the other avenues available to access catheters in the community. In addition, following the implementation of the EMAR system at Copperfields in February 2022, all staff were provided with several weeks of EMAR training and have access to 24 hours a day support from the EMAR team. The nurses and management team have been trained to review the stock”

Source location
2022-0024-Response-from-Exemplar-Health-Care_Published
Page 2 · response
Published 31 January 2022
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
Digitise EQA governance and establish team-leader accountability, daily management reviews, clinical walkarounds, take-twenty meetings and electronic quality-assurance tracking.

Verbatim wording from the response
“In addition to these management changes, specific steps have also been taken to ensure greater management overview, and quality assurance, of record keeping and documentation. During Mr Athias' residence at Copperfields the relevant governance processes (EQA- External Quality Assurance) were paper based. However, the majority of the EQA processes have now been moved to a digital platform.”

Source location
2022-0024-Response-from-Exemplar-Health-Care_Published
Page 3 · response
Published 31 January 2022
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 monthly audits of supplementary and care files, with findings discussed with unit managers.

Verbatim wording from the response
“9. Copperfields has implemented monthly auditing of supplementary and care files and findings are discussed with individual unit managers.”

Source location
2022-0024-Response-from-Exemplar-Health-Care_Published
Page 5 · response
Published 31 January 2022
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
Deliver workshops and coaching on creating, implementing and monitoring unambiguous care plans and comprehensive records across all service users.

Verbatim wording from the response
“Further workshops and coaching sessions have also been undertaken by various experienced Quality Managers in order to support staff to create, implement and monitor more thorough and unambiguous care plans. In the first instance this support was focussed on the documentation for service users who utilised catheters, however the workshops have now been undertaken in relation to all service users and included general sessions on record keeping and documentation. You heard evidence from Ms ████████ that significant management change has now taken place at Copperfields since Mr Athias' death. A new Registered Home Manager and new Clinical Nurse Manager are now in place. In addition, a second full time Clinical Nurse Manager and a full time Head of Care have been employed.”

Source location
2022-0024-Response-from-Exemplar-Health-Care_Published
Page 3 · response
Published 31 January 2022
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing management oversight, quality assurance and governance processes are considered sufficient to ensure records are kept, retained and reviewed for trends.

Verbatim wording from the response
“I have detailed above the relevant management structure changes and quality assurance systems in place to ensure that all record keeping is appropriate and accurate. In summary:”

Source location
2022-0024-Response-from-Exemplar-Health-Care_Published
Page 4 · response
Published 31 January 2022
Open published response
17 Dec2021
Manchester North
Concerns raised1
1. Failure to maintain nutrition and fluid charts
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Nichola Jane Lomax · 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

Nichola Jane Lomax had a long history of an eating disorder and attended hospital several times in 2020 with severe malnutrition and electrolyte imbalance. She died on 3 August 2020 after delays and failings involving hospital treatment, specialist referral, communication, monitoring, nutritional care and access to appropriate services. The report identified concerns about inadequate eating-dis disorder training, access to specialist advice, referral criteria, critical services, community monitoring, nursing care and investigation of deaths.

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 maintain nutrition and fluid charts
Wider context from the report
“6) Nursing Input and Recording For NCA Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information. ”
Source location
Nichola Jane Lomax · Prevention of Future Deaths report
Page 3 · concerns
Open source report
20 Jul2021
Norfolk
Concerns raised1
1. Failure of the care recording system to support accessible and complete food and fluid intake records
This report raised 19 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
  Develop and improve the Pandora information system through a staff user group.
  Stated by Jeesal Residential Care Services LimitedStated in progress
Respondent positions 1
1. Position
  A paper-based care system is considered detrimental because it would undermine remote monitoring, statistical analysis and a whole-system approach.
  Stated by Jeesal Residential Care Services LimitedDisputes the concern
AI-generated summary

Ben Buster KING · 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

Ben Buster KING was detained under the Mental Health Act at Jeesal Cawston Park and died in hospital on 29 July 2020 after becoming unwell following respiratory problems and receiving sedative medication. The inquest identified concerns including failure to diagnose obesity hypoventilation syndrome, inadequate consideration of promethazine, failure to recognise the seriousness of a life-threatening situation, and wider care, observation, record-keeping and hospital communication 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 of the care recording system to support accessible and complete food and fluid intake records
Wider context from the report
“8. JCP used the Pandora software system, (company Directors for Pandora are the same as for JHL and JRCSL) which is still used at the residential homes owned by JHL and JRCSL. Concerns were raised at the inquest in respect of this software system in that not all policies and documents were available to staff on the IPads provided, some of the documents were unwieldy and difficult to read (eg Personal Healthcare Plan), the Dietician recommended use of paper records in respect of Food and Fluid intake as these would be more accessible to staff and encourage the documents to be completed or in the alternative providing for the records on Ipads to be more easy to access and complete ”
Source location
Ben Buster KING · 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
Develop and improve the Pandora information system through a staff user group.

Verbatim wording from the response
“6. The MD and members of the GAT have access to every resident’s care file, we also have access to a whole range of information on each resident, all of which we can access remotely. The GAT carries out regular service reviews and unannounced inspections. Where there are deficiencies, the GAT will work with the Registered Manager to correct these deficiencies which may include report writing, care planning, risk assessments and healthy living plans. As an example, the GAT recently found inconsistencies in recording of information on Pandora, with some confusion as to record entries. This led to the establishment of a Pandora User Group, to work with homes to improve consistency of recording and content.”

Source location
2021-0250-Response-from-Jeesal-Residential-Care-Services_Published
Page 3 · response
Published 23 July 2021
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
A paper-based care system is considered detrimental because it would undermine remote monitoring, statistical analysis and a whole-system approach.

Verbatim wording from the response
“We note the suggestion by the Dietician to have a paper-based system. We am resistant to this as this will undermine my ability and the ability of GAT and external colleagues to monitor remotely. I consider a two-system approach to be detrimental when trying to achieve a whole system approach to care and support. Unlike a hospital where the patients are in one place, our residential services are spread across the county and as such, while physical attendance at a home is important, so too is remote access. In addition, the Pandora system allows us to carry out statistical analysis and monitor trends.”

Source location
2021-0250-Response-from-Jeesal-Residential-Care-Services_Published
Page 4 · response
Published 23 July 2021
Open published response
19 Oct2020
Blackpool and the Fylde
Concerns raised1
1. 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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. 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 TrustStated planned
2. 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 TrustStated completed
AI-generated summary

Douglas OWENS · 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

Douglas Robert Owens developed acute cardiac failure, hypotension, aspiration pneumonia and multi-organ failure after cataract surgery, treatment for raised intraocular pressure, ongoing eye pain and painful urinary retention. He died in intensive care on 7 July 2018. Concerns included arrangements for urgent ophthalmic transfer, specialist assessment, monitoring and review of deterioration, fluid documentation, and recording medication doses.

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 complete prescription and fluid balance charts for prescribed fluids
Wider context from the report
“(5)That the evidence disclosed the fact that, whilst fluids had been prescribed, no prescription chart or fluid balance chart had been completed. Unless action is taken to ensure the completion of applicable documentation, the lives of patients may be put at risk. ”
Source location
Douglas OWENS · 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
Conduct regular Emergency Department spot audits and huddles to verify NEWS2 recording, prompt escalation and completion of fluid charts.

Verbatim wording from the response
“In the interim, the Head of the Emergency Department and the Matron will ensure senior clinical staff will undertake regular spot audits / huddles, to ensure all patients in the ED have their NEWS2 score recorded correctly, that any changes in score are acted upon promptly and that fluid charts are completed correctly and acted upon promptly. The ED complete a Consistency in Care Audit daily, where 40 patients’ notes (approximately 20% of all patients daily) are reviewed in real time and this includes a review of the NEWS 2 and fluid balance. This is used to monitor the compliance and manage any inconsistencies in care at the time. Additionally the ED undertakes an intentional round, where all patients who have been in the department for longer than 4 hours, are reviewed by the EPIC (Emergency Physician in Charge) to ensure that appropriate plans of care are in place.”

Source location
2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
Page 3 · response
Published 3 December 2020
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
Complete daily real-time Consistency in Care Audits reviewing NEWS2 and fluid-balance compliance and manage identified inconsistencies.

Verbatim wording from the response
“In the interim, the Head of the Emergency Department and the Matron will ensure senior clinical staff will undertake regular spot audits / huddles, to ensure all patients in the ED have their NEWS2 score recorded correctly, that any changes in score are acted upon promptly and that fluid charts are completed correctly and acted upon promptly. The ED complete a Consistency in Care Audit daily, where 40 patients’ notes (approximately 20% of all patients daily) are reviewed in real time and this includes a review of the NEWS 2 and fluid balance. This is used to monitor the compliance and manage any inconsistencies in care at the time. Additionally the ED undertakes an intentional round, where all patients who have been in the department for longer than 4 hours, are reviewed by the EPIC (Emergency Physician in Charge) to ensure that appropriate plans of care are in place.”

Source location
2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
Page 3 · response
Published 3 December 2020
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Poor completion of fluid balance charts

Concerns raised1

Lack of effective, reliable recording of intravenous fluids administered in the emergency department

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure to put fluid balance charts in place

Poor maintenance of clinical records of fluid administration

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 raised2

Inaccurate recording of food intake

Failure to record fluid intake directly by the estimating staff

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 raised1

Failure to maintain complete records of fluid provision and pad status

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to record fluid intake accurately

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure of managers to detect inadequate monitoring records

Inadequate contemporaneous records of fluid intake and output

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 2

Respondent positions 1

Actions described in response 5

Actions described in response 1

Respondent positions 1

Actions described in response 4

Respondent positions 1

Actions described in response 4

Respondent positions 1