Recurring concern

Unreliable recording of fluid balance information

First to latest report 6 Nov 2013 — 22 Dec 2025

Reports that mention this concern
46
Times this concern has been raised
50
Stated actions linked to this concern
87

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.

What is 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 and published responses 46 reports

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

  1. Manchester South

    AI-generated summary

    DAVID CRAIG KERR · 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

    David Kerr was admitted to hospital after a fall at home and subsequently sustained a fractured neck of femur in a further ward fall after removing his oxygen. He became increasingly unwell and died on 27 April 2019; the inquest recorded accidental death, with respiratory failure and extensive idiopathic pulmonary fibrosis as the medical cause of death. Concerns included poor care on Ward D2, inadequate hydration and fluid recording, and too few clinical observations for a seriously unwell 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

    Failure to complete input/output charts for seriously unwell patients

    Wider context from the report

    “(2) Between 24th and 26th April DK was allowed to become increasingly dehydrated; on 24th April he received a total of 300mls of fluid and the input/output chart was not filled in on 25th/26th April, despite the fact that he was seriously unwell. ”

    Source location

    DAVID CRAIG KERR · 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

    Reinforce accurate fluid-balance review and investigation of alternative causes of hypotension.

    Verbatim wording from the response

    “We have discussed his case with consultants across all clinical business groups and agreed the following Trust wide actions:”

    Source location

    2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
    Page 2 · response
    Published 18 May 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

    Speak to staff involved and remind them to record fluid balances accurately.

    Verbatim wording from the response

    “In order to ensure compliance with best practice standards in Ward D2, the following actions are being taken:”

    Source location

    2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
    Page 2 · response
    Published 18 May 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

    Deliver ward training on timely and accurate fluid-balance recording.

    Verbatim wording from the response

    “In order to ensure compliance with best practice standards in Ward D2, the following actions are being taken:”

    Source location

    2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
    Page 2 · response
    Published 18 May 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

    Audit ward fluid-balance recording daily, provide feedback, and obtain external peer reviews for objectivity.

    Verbatim wording from the response

    “In order to ensure compliance with best practice standards in Ward D2, the following actions are being taken:”

    Source location

    2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
    Page 2 · response
    Published 18 May 2020

    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 records showed positive, though declining, fluid balance, so the response disputes that the patient became increasingly dehydrated.

    Verbatim wording from the response

    “Between 24th and 26th April 2019, Mr Kerr was allowed to become increasingly dehydrated; on 24th April he received a total of 300mls of fluid and the input/output chart was not filled in on 25th/26th April, despite the fact that he was seriously unwell.”

    Source location

    2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
    Page 2 · response
    Published 18 May 2020

    Open published response

  2. Inner North London

    AI-generated summary

    John Francis GREGORY · 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

    John Francis Gregory died after developing acute kidney injury associated with low oral fluid intake, in the context of Alzheimer’s disease and old age. Concerns included inadequate encouragement and monitoring of drinking in hospital rehabilitation and residential care, inaccurate fluid-intake records, and failures to escalate or respond to his deterioration at Muriel Street Resource Centre.

    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 patients’ fluid intake

    Wider context from the report

    “4. Mr Gregory’s oral fluid intake was also too low at Muriel Street, a nursing home specialising in the care of those with dementia. On his last day at the home, Mr Gregory was described in the nursing notes as drinking, but his chart showed that he had drunk nothing since a cup of tea at 8.20am. The ambulance was called at 5.17pm. The fact that he had not drunk the whole day was not escalated to a senior member of staff and there was no evidence that any steps had been taken to deal with this. His fluid intake chart recorded him as repeatedly declining drinks, even at a time after he had lost consciousness and an ambulance had already been called for him. This demonstrates that the chart was inaccurate. It raises the possibility that the chart was inaccurate in other ways. It raises the possibility that when Mr Gregory was described as declining drinks, in fact staff were not taking any steps to encourage him to drink, or to eat. ”

    Source location

    John Francis GREGORY · 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

    Introduce clearer fluid-balance and fluid-target charts, train staff in their use, and include them in documentation audits.

    Verbatim wording from the response

    “Muriel Street has reviewed the fluid charts used and has introduced new fluid balance monitoring documentation – copies attached. The new charts are clearer and enable details of a resident's input / output to be recorded in more detail. Further, staff are now instructed to document when the re-attempt to provide oral fluids to ensure that there is evidence of active encouragement.”

    Source location

    2020-0073-Response-from-Care-UK_Redacted
    Page 5 · response
    Published 9 April 2020

    Open published response

  3. Central and South East Kent

    AI-generated summary

    Lynda Pedersen · 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

    Lynda Pedersen died on 7 September 2018 in hospital from aspiration pneumonitis, pneumonia and fluid overload due to a stricture caused by an adenocarcinoma of the oesophagogastric junction. The adenocarcinoma was not identified during her admission or during earlier medical care following an admission for dysphagia. Concerns included the lack of a pathway for investigating dysphagia caused by a stricture, which contributed to the need to investigate malignancy being lost, and deficiencies in fluid balance charting and recording of fluid output before her 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 accurately complete and reconcile fluid balance charts

    Wider context from the report

    “(2) Fluid balance charts were not correctly completed in the period leading to Lynda Pedersen’s death. The evidence from the fluid balance charts showed that she was carrying fluids forward until the time of her death; there being an imbalance to the tune of some 3 1/2 litres. That there was a significant fluid overload was also evident from the pathology. That she had a fluid overload was only identified by the hospital at a time that she was temporally close to death. It was accepted at the inquest that the charts were deficient in their completion, that nursing staff had not recorded output properly or reconciled the balance as required. ”

    Source location

    Lynda Pedersen · 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

    Support clinical leadership teams to understand roles and responsibilities for accurate fluid-balance monitoring.

    Verbatim wording from the response

    “The Trust is focused on improving how we monitor fluid balance through the completion of fluid balance charts in all areas of the Trust. We have addressed this through supporting our clinical leadership teams in understanding their roles and responsibilities to ensure best practice in their wards by medical and nursing teams. We have undertaken multi-disciplinary education programmes on the importance of accurate fluid balance monitoring and regularly audit of the completion of fluid balance charts. Our Deteriorating Patient Group leads on monitoring audit results regarding accurate completion of fluid balance charts with ward managers taking responsibility for their results and making improvement where required.”

    Source location

    2020-0112-Response-from-East-Kent-Hospitals-Trust.pdf
    Page 2 · response
    Published 10 June 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

    Deliver multidisciplinary education on the importance of accurate fluid-balance monitoring.

    Verbatim wording from the response

    “The Trust is focused on improving how we monitor fluid balance through the completion of fluid balance charts in all areas of the Trust. We have addressed this through supporting our clinical leadership teams in understanding their roles and responsibilities to ensure best practice in their wards by medical and nursing teams. We have undertaken multi-disciplinary education programmes on the importance of accurate fluid balance monitoring and regularly audit of the completion of fluid balance charts. Our Deteriorating Patient Group leads on monitoring audit results regarding accurate completion of fluid balance charts with ward managers taking responsibility for their results and making improvement where required.”

    Source location

    2020-0112-Response-from-East-Kent-Hospitals-Trust.pdf
    Page 2 · response
    Published 10 June 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

    Audit fluid-balance chart completion and monitor results through the Deteriorating Patient Group, with ward managers responsible for improvement.

    Verbatim wording from the response

    “The Trust is focused on improving how we monitor fluid balance through the completion of fluid balance charts in all areas of the Trust. We have addressed this through supporting our clinical leadership teams in understanding their roles and responsibilities to ensure best practice in their wards by medical and nursing teams. We have undertaken multi-disciplinary education programmes on the importance of accurate fluid balance monitoring and regularly audit of the completion of fluid balance charts. Our Deteriorating Patient Group leads on monitoring audit results regarding accurate completion of fluid balance charts with ward managers taking responsibility for their results and making improvement where required.”

    Source location

    2020-0112-Response-from-East-Kent-Hospitals-Trust.pdf
    Page 2 · response
    Published 10 June 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

    Provide clinical induction training on completing and reviewing fluid-balance charts daily.

    Verbatim wording from the response

    “In addition, all our clinical staff complete clinical induction days to ensure they understand the importance of completing fluid balance charts and reviewing these daily and our critical care outreach teams provide support and teaching to ward staff on the importance of completing fluid balance. This concludes our response to your concern.”

    Source location

    2020-0112-Response-from-East-Kent-Hospitals-Trust.pdf
    Page 2 · response
    Published 10 June 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

    Provide ward staff with critical-care outreach support and teaching on completing fluid-balance charts.

    Verbatim wording from the response

    “In addition, all our clinical staff complete clinical induction days to ensure they understand the importance of completing fluid balance charts and reviewing these daily and our critical care outreach teams provide support and teaching to ward staff on the importance of completing fluid balance. This concludes our response to your concern.”

    Source location

    2020-0112-Response-from-East-Kent-Hospitals-Trust.pdf
    Page 2 · response
    Published 10 June 2020

    Open published response

  4. Manchester South

    AI-generated summary

    Mary Jones · 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

    Mary Jones had an accidental unwitnessed fall, was treated surgically and transferred for rehabilitation, and died on 3 March 2019 after developing acute pneumonia alongside congestive heart failure and acute kidney injury. Concerns included an out-of-hours transfer and admission, delayed falls-risk assessment, poor fluid-chart documentation, loss of records during an IT merger, absent or untraceable nutrition-related referrals, and no clear clinical review of fluid-chart outcomes.

    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-quality nursing documentation of fluid charts

    Wider context from the report

    “3. The documentation within the nursing notes, particularly the fluid charts was poor quality, making it difficult to understand what had happened in relation to the hydration of Mrs Jones; ”

    Source location

    Mary Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Manchester City

    AI-generated summary

    Ann Corfield · 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

    Ann Corfield was admitted to hospital with a urinary tract infection, low sodium levels and deteriorating mental health, later developing severe psychotic depression, poor oral intake and dehydration. She suffered a cardiac arrest and died after transfer between hospitals. Concerns included inadequate handover about anticoagulation, failure to administer prescribed prophylactic anticoagulation, poor completion of fluid balance charts, and the lack of suitably qualified staff to administer intravenous fluids at Park House.

    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 fluid balance charts accurately and consistently

    Wider context from the report

    “2. Dehydration clearly played a part in Mrs Corfield’s death. I heard evidence at Inquest that Fluid Balance Charts were poorly completed indeed some of them were not completed at all or contained errors with simple arithmetic. At the Inquest, I heard conflicting evidence about the usefulness of fluid balance charts. Witnesses who were employed by Pennine Acute Trust tended to place more reliance on the results of blood tests. However, ████████ emphasised to me the importance of FBC charts in a patient like Mrs Corfield who had a history of chronic kidney disease because blood tests were an ‘insensitive measure’ of hydration. I received helpful written evidence from ████████ who is the Divisional Director of Nursing for Medicine at Royal Oldham Hospital, dated 31st January 2019, which, at paragraph 17, shows there are still ongoing problems with the way fluid balance charts are completed some two and a half years after Mrs Corfield’s death. ”

    Source location

    Ann Corfield · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. Manchester South

    AI-generated summary

    Michael William Flynn · 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 William Flynn underwent elective hip replacement surgery and required a blood transfusion. He subsequently experienced inadequate Early Warning Score monitoring, failures to follow escalation procedures, incomplete fluid-balance monitoring, and a lack of timely clinical review before suffering cardiac arrest and dying on 17 July 2018.

    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 fluid balance charts and calculate fluid position

    Wider context from the report

    “10. A fluid balance chart was requested and fluids prescribed. It was not completed fully and in particular the necessary calculations to understand Mr Flynn's fluid position were not made. The trust policy was not followed regarding completion. The doctor who saw Mr Flynn on the morning of 16th July 2018 prescribed further fluids without reference to the fluid charts. ”

    Source location

    Michael William Flynn · 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

    Introduced bedside signage identifying patients with fluid balance charts.

    Verbatim wording from the response

    “In regard to the fluid balance chart, I have been assured by the Matron for the Orthopaedic Unit that formal discussions have taken place with the nursing staff identified as failing to comply with Trust Policy in respect to the completion of the fluid balance chart and consideration given to identify support or training needs. In addition, the newsletter previously referred to, circulated to all staff in the department, reiterates staff responsibilities and accountability regarding completion of the fluid balance chart. As an additional measure, I understand the ward manager has recently introduced new signage placed at the bedside to further support staff in recognizing which patients have a fluid balance chart in place.”

    Source location

    2019-0008-Response-by-Tameside-and-Glossop-Care-NHS-Trust
    Page 5 · response
    Published 23 May 2019

    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

    Added a Trust-wide fluid balance chart compliance audit to the 2019/2020 Audit Programme.

    Verbatim wording from the response

    “I am aware that an audit of fluid balance charts has recently been completed, as part of a wider audit of the Trust’s Acute Kidney Injury care pathway. The results identify 100% compliance in completion of the fluid balance chart. Whilst this provides a level of assurance, the Head of Clinical Audit and Effectiveness has indicated that a trust wide audit of fluid balance chart compliance has been added to the Trust Audit Programme for 2019/2020.”

    Source location

    2019-0008-Response-by-Tameside-and-Glossop-Care-NHS-Trust
    Page 5 · response
    Published 23 May 2019

    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

    Distributed a learning bulletin on monitoring and completing fluid balance charts.

    Verbatim wording from the response

    “The Medical Education Manager has advised that fluid balance management is included in the AIMS training that is provided to junior doctors commencing at the Trust and the Patient Safety Team have drafted and distributed a ‘Time out for Learning’ bulletin focusing on the importance of monitoring and completing fluid balance charts.”

    Source location

    2019-0008-Response-by-Tameside-and-Glossop-Care-NHS-Trust
    Page 5 · response
    Published 23 May 2019

    Open published response

  7. Brighton and Hove

    AI-generated summary

    Kalma RAM-HENMAN · 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

    Kalma RAM-HENMAN died on 7 June 2018 after presenting to A&E in a precarious state and later being found to have a perforated gastric ulcer. The report identified concerns about incomplete fluid monitoring, failure to administer prescribed potassium and sufficient intravenous fluids, missed ECG abnormalities, inadequate repeat blood testing, and delays in responding to her deterioration and providing planned treatment.

    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 an accurate fluid balance chart and measure urine output

    Wider context from the report

    “(1) This lady arrived in A&E in a “precarius” state as the blood test results revealed and there were several failings:- The attending Doctor required an accurate fluid chart. This was started. It was incompletely filled out and showed no output and no attempts were made to measure urine output. As a result, Doctors and Nurses were unaware of just how dehydrated Mrs RAM-HENMAN was becoming. ”

    Source location

    Kalma RAM-HENMAN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Inner North London

    AI-generated summary

    Angela Sandra Ivina West · 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

    Angela Sandra Ivina West had end stage kidney disease and underwent gall bladder removal surgery on 6 July 2017. She deteriorated over the following days, with tachycardia, acidosis, hyperkalaemia and hypovolemia, and died after suffering a cardiac arrest on 9 July 2017. Concerns included weekend staffing arrangements, her care on a general surgical ward, and the absence of fluid balance charts in relation 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

    Lack of fluid balance chart availability

    Wider context from the report

    “(3) The investigation highlighted issues relating to Ms West becoming dehydrated. Neither myself nor the clinical investigators were able to locate any fluid balance charts for Ms West. ”

    Source location

    Angela Sandra Ivina West · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Manchester North

    AI-generated summary

    Mrs Lindsey Parker · 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

    Mrs Lindsey Parker had metastatic lung cancer and subsequently developed toxic epidermal necrolysis while receiving medical treatment. Her condition deteriorated on 8 July 2017, with concerns about delayed medical review, inadequate recognition and escalation of deterioration, gaps in observations and fluid-balance recording, lack of continuity in medical care, and the qualifications of out-of-hours coordinators. She died at Salford Royal Hospital on 9 July 2017.

    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

    Inadequate completion of fluid balance charts

    Wider context from the report

    “2. Matron's review identified gaps in basic nursing care – vital signs/observations not recorded, potentially affecting the NEWS and inadequate fluid balance chart completion. Both are critical to patient care and safety, particularly given Mrs Parker's serious clinical diagnosis (TEN), against a backdrop of an already life limiting/threatening diagnosis. ”

    Source location

    Mrs Lindsey Parker · 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

    Update ward safety-huddle content to identify patients requiring hourly urine-output monitoring and address responses to deteriorating NEWS scores.

    Verbatim wording from the response

    “Mrs Parker was having her fluid balance monitored (fluid intake measured against urine output to ensure hydration). Patients with the condition TEN can lose high amounts of fluid through their skin and it is essential to monitor the urine output as this will indicate if a patient is becoming dehydrated. Mrs Parker was having her urine output measured hourly and the overall daily balance would have been calculated at midnight. On two occasions the urine output was not charted hourly. This is below the expected standard and the individuals have reflected upon their practice and learned from this event. The Ward Matron has also discussed the learning with the ward team and made changes to the content of the daily ward safety huddle to acknowledge which patients are requiring hourly urine output monitoring.”

    Source location

    2017-0378-Response-by-Northern-Care-Alliance-NHS-Group
    Page 4 · response
    Published 12 February 2018

    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 weekly senior-nurse audits of fluid-balance charts to monitor maintenance of required recording standards.

    Verbatim wording from the response

    “Mrs Parker was having her fluid balance monitored (fluid intake measured against urine output to ensure hydration). Patients with the condition TEN can lose high amounts of fluid through their skin and it is essential to monitor the urine output as this will indicate if a patient is becoming dehydrated. Mrs Parker was having her urine output measured hourly and the overall daily balance would have been calculated at midnight. On two occasions the urine output was not charted hourly. This is below the expected standard and the individuals have reflected upon their practice and learned from this event. The Ward Matron has also discussed the learning with the ward team and made changes to the content of the daily ward safety huddle to acknowledge which patients are requiring hourly urine output monitoring.”

    Source location

    2017-0378-Response-by-Northern-Care-Alliance-NHS-Group
    Page 4 · response
    Published 12 February 2018

    Open published response

  10. South Wales Central

    AI-generated summary

    Hedley Greenland · 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

    Hedley Greenland, who was residing in a nursing home and had prostate cancer requiring permanent catheterisation, became acutely unwell on 17 December 2016 and died in hospital on 20 December 2016. The inquest concluded that he died from the effects of a urine infection in circumstances where fluid input and catheter output were not adequately monitored for over nine hours. Concerns included the absence of fluid balance monitoring and written handover, inadequate catheter-care training and knowledge, and the absence of evidence that the Catheter Care Bundle was being used.

    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 use fluid balance charts to monitor fluid intake and urine output

    Wider context from the report

    “(1) A fluid balance chart should have been used by nursing staff to monitor fluid intake and urine output. There was no evidence that one had been thus rendering it impossible to measure urine output which might have indicated a blockage and/or infection. It was apparent during the course of the evidence that the nurse in charge of Mr Greenland's care did not consider actively monitoring his urine output, neither did she consider flushing the catheter. There was no written handover, as the evidence showed is normally the practice, to the incoming nursing team the following morning. There was no clear evidence that the lack of urine output had been noted by the night shift with a view to escalating his care. The evidence revealed that there was no urine output for at least 9 hours but probably substantially more than that. ”

    Source location

    Hedley Greenland · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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

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Data last updated 7 September 2026