Recurring concern

Unsafe clinical management of hyponatraemia

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First reported 25 Jul 2014•Latest report 12 Jun 2018

Definition

What this concern includes

Includes deficiencies in the clinical assessment, investigation, decision-making or treatment of hyponatraemia, including inadequate understanding of its causes, investigation thresholds or appropriate management.

Not included

Excludes deficiencies concerning other electrolyte abnormalities unless the report explicitly ties them to hyponatraemia management.
Excludes generic clinical training, consultant capability or communication concerns that are not specifically dedicated to hyponatraemia.
Excludes unrelated delays, documentation failures or failures of escalation unless they directly concern the safe investigation or management of hyponatraemia.

Reports: 2
Individual concerns: 7
Date range: 2014–2018
Stated actions: 12

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.

Royal College of Physicians2

Care Quality Commission1

Epsom Hospital1

NHS Surrey and Sussex Integrated Care Board1

Royal College of Pathologists1

Royal College of Psychiatrists1

Surrey and Borders Partnership NHS Foundation Trust1

Woodlands Surgery1

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.

12 Jun2018
Surrey
Concerns raised5
1. Lack of consultant understanding of appropriate hyponatraemia management
2. Failure to obtain appropriate specialist assistance for hyponatraemia management
3. Failure to complete specialist consultation for hyponatraemia management
1. Failure to follow recommended hyponatraemia monitoring and treatment guidelines
2. Failure to establish a management plan for hyponatraemia
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 9
1. Action
  Move the handbook of medical emergencies, including hyponatraemia guidance, to the Trust intranet for easier staff access.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated completed
2. Action
  Update and relaunch the guidance for managing hyponatraemia through the Medicines Management Committee approval process.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated in progress
3. Action
  Share the updated hyponatraemia guidance with all clinical staff.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated planned
1. Action
  Arrange education on the updated hyponatraemia guidance.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated planned
2. Action
  Classify desmopressin as a high-risk drug requiring specialist advice before discontinuation and a plan for reintroduction.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated completed
3. Action
  Develop a pro-forma documenting hyponatraemia monitoring plans, including sodium targets, risks of rapid correction and when to consider restarting desmopressin.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated in progress
4. Action
  Review the feasibility of cohorting patients requiring the highest acuity of care in a specialist ward area.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated in progress
5. Action
  Introduce Care View on the Acute Medical Unit to communicate high-risk patients and their management plans.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated planned
6. Action
  Circulate the prevention-of-future-deaths concerns to all Trust consultants and remind them of documentation accountabilities and Royal College of Physicians standards.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated completed
AI-generated summary

Rita Taylor · 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

Rita Taylor was admitted to hospital with severe hyponatraemia in the context of diabetes insipidus and a pituitary adenoma, and died on 15 August 2017 after developing central pontine myelinolysis. The principal concerns were failures to appropriately monitor and manage her sodium levels and diabetes insipidus, including omission of desmopressin, inadequate fluid-balance assessment, insufficient documentation, and lack of a coherent management plan.

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 consultant understanding of appropriate hyponatraemia management
Wider context from the report
“4. The apparent lack of understanding of the appropriate management of hyponatraemia by consultants whose care Mrs Taylor was under, despite two emergency consultant physicians having a specialist interest in endocrinology. Whilst some attempt was made to contact St George’s hospital this was not successfully followed through to assist them in their management. ”
Source location
Rita Taylor · Prevention of Future Deaths report
Page 5 · 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 obtain appropriate specialist assistance for hyponatraemia management
Wider context from the report
“1. The failure to appropriately manage Mrs Taylor’s hyponatraemia by the on call consultant physician on the 31st July 2017 on the grounds that it was not his sphere of expertise. No contact was considered or made to someone who may have been able to assist leaving Mrs Taylor to languish overnight with no management plan in place and a lack of any meaningful documentation in her hospital notes. ”
Source location
Rita Taylor · Prevention of Future Deaths report
Page 4 · 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 complete specialist consultation for hyponatraemia management
Wider context from the report
“4. The apparent lack of understanding of the appropriate management of hyponatraemia by consultants whose care Mrs Taylor was under, despite two emergency consultant physicians having a specialist interest in endocrinology. Whilst some attempt was made to contact St George’s hospital this was not successfully followed through to assist them in their management. ”
Source location
Rita Taylor · Prevention of Future Deaths report
Page 5 · 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 follow recommended hyponatraemia monitoring and treatment guidelines
Wider context from the report
“2. The failure, at any time between the 31st July 2017 and 5th August 2017 to follow the national recommended guidelines for the management and treatment of hyponatraemia, in particular the need to measure serum sodium regularly and to limit the rate of rise of serum sodium to prevent complications. ”
Source location
Rita Taylor · Prevention of Future Deaths report
Page 4 · 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 establish a management plan for hyponatraemia
Wider context from the report
“1. The failure to appropriately manage Mrs Taylor’s hyponatraemia by the on call consultant physician on the 31st July 2017 on the grounds that it was not his sphere of expertise. No contact was considered or made to someone who may have been able to assist leaving Mrs Taylor to languish overnight with no management plan in place and a lack of any meaningful documentation in her hospital notes. ”
Source location
Rita Taylor · Prevention of Future Deaths report
Page 4 · 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
Move the handbook of medical emergencies, including hyponatraemia guidance, to the Trust intranet for easier staff access.

Verbatim wording from the response
“Response - The Trust has moved the handbook of medical emergencies, which includes guidance on the management of hyponatraemia, to the Trust intranet, which can be more easily accessed by staff. (See Recommendation 1 of the Action Plan). This was completed in August 2018.”

Source location
2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 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
Update and relaunch the guidance for managing hyponatraemia through the Medicines Management Committee approval process.

Verbatim wording from the response
“Recommendation 2 of the Action Plan confirms the guidance on the management of hyponatraemia will be updated and relaunched. The guidance has been updated and is currently going through the approval process with the Medicines Management Committee which is made up of clinical representatives across the hospital. The Trust’s Communication Team will share the updated guidance with all clinical staff and appropriate education around the updated guidance will be arranged.”

Source location
2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 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
Share the updated hyponatraemia guidance with all clinical staff.

Verbatim wording from the response
“Recommendation 2 of the Action Plan confirms the guidance on the management of hyponatraemia will be updated and relaunched. The guidance has been updated and is currently going through the approval process with the Medicines Management Committee which is made up of clinical representatives across the hospital. The Trust’s Communication Team will share the updated guidance with all clinical staff and appropriate education around the updated guidance will be arranged.”

Source location
2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 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
Arrange education on the updated hyponatraemia guidance.

Verbatim wording from the response
“Recommendation 2 of the Action Plan confirms the guidance on the management of hyponatraemia will be updated and relaunched. The guidance has been updated and is currently going through the approval process with the Medicines Management Committee which is made up of clinical representatives across the hospital. The Trust’s Communication Team will share the updated guidance with all clinical staff and appropriate education around the updated guidance will be arranged.”

Source location
2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 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
Classify desmopressin as a high-risk drug requiring specialist advice before discontinuation and a plan for reintroduction.

Verbatim wording from the response
“Response - Recommendation 5 of the Action Plan sets out that; ‘Desmopressin should be notified as a high risk drug that should not be discontinued without specialist advice.’ The specialist providing the advice to discontinue the drug will ensure that there is a plan in place to reintroduce the drug at an appropriate time. This action has been implemented by the Medicines Management Committee with input from the pharmacy department.”

Source location
2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Page 4 · response
Published 23 September 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
Develop a pro-forma documenting hyponatraemia monitoring plans, including sodium targets, risks of rapid correction and when to consider restarting desmopressin.

Verbatim wording from the response
“Response - The AMU lead within the Trust is devising a new pro-forma for the documentation of monitoring plans for patients. Recommendation 6 of the RCA report specifies the need for the monitoring plan for patients with hyponatraemia to set out the desired rate of rise of that patient’s sodium and the risks associated with a rise steeper than this. The monitoring plan will also set out when to consider restarting medication such as desmopressin. The Trust has also set up a Task and Finish Group to review the feasibility of cohorting patients needing the highest acuity of care, (which would include those patients who need regular blood tests), with the ambition that these patients are placed in a specialist ward area from April 2019 to facilitate more regular reviews of their management.”

Source location
2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 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
Review the feasibility of cohorting patients requiring the highest acuity of care in a specialist ward area.

Verbatim wording from the response
“Response - The AMU lead within the Trust is devising a new pro-forma for the documentation of monitoring plans for patients. Recommendation 6 of the RCA report specifies the need for the monitoring plan for patients with hyponatraemia to set out the desired rate of rise of that patient’s sodium and the risks associated with a rise steeper than this. The monitoring plan will also set out when to consider restarting medication such as desmopressin. The Trust has also set up a Task and Finish Group to review the feasibility of cohorting patients needing the highest acuity of care, (which would include those patients who need regular blood tests), with the ambition that these patients are placed in a specialist ward area from April 2019 to facilitate more regular reviews of their management.”

Source location
2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 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
Introduce Care View on the Acute Medical Unit to communicate high-risk patients and their management plans.

Verbatim wording from the response
“Care View, an electronic handover system which allows high risk patients and their management plans to be communicated more effectively is also to be introduced to AMU.”

Source location
2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 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
Circulate the prevention-of-future-deaths concerns to all Trust consultants and remind them of documentation accountabilities and Royal College of Physicians standards.

Verbatim wording from the response
“Response - The Trust is reviewing how we monitor compliance with our Health Record Content policy which outlines the record keeping standards for Trust staff. There are 14 standards set out within this policy which have been taken from the guidance provided by the Royal College of Physicians. There will be a twice annual audit of the 14 standards set out within the policy which will include an assessment of the requirement to include ‘clear evidence of the arrangements made for future and ongoing care’. The Joint Medical Director and Deputy Chief Executive has also circulated a copy of the concerns raised in the Report to Prevent Future Deaths to all consultants within the Trust and has reminded them of their accountabilities around the documentation of management plans and reminded them of the standards for documentation set by the Royal College of Physicians.”

Source location
2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Page 4 · response
Published 23 September 2018
Open published response
25 Jul2014
Surrey
Concerns raised2
1. Lack of understanding of hyponatraemia causes, investigation thresholds and required investigations
2. Insufficiently clear published guidance on the causes, investigation and treatment of low blood sodium
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Deliver a Trust-wide academic teaching session for Eating Disorder Service clinical staff on Addison’s disease, hyponatremia, and thresholds for further investigation.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated planned
2. Action
  Complete the BMJ hyponatraemia learning module and record the learning need in professional development plans for appraisal submission.
  Stated by Woodlands SurgeryStated planned
3. Action
  Hold a practice educational meeting on hyponatraemia and Addison’s disease with a consultant endocrinologist.
  Stated by Woodlands SurgeryStated planned
Respondent positions 1
1. Position
  Advice on concerns relating to hospital medicine should be obtained from hospital medicine rather than the College.
  Stated by Royal College of General PractitionersRedirects responsibility
AI-generated summary

Clare Serena Anke COOPER · 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

Clare Serena Anke Cooper, a young adult, developed weight loss, lassitude, dizziness, nausea, difficulty eating and an intermittently low blood sodium level before dying after a cardiorespiratory arrest and hospital admission. The inquest concluded that she died from the consequences of undiagnosed Addison’s disease and an Addisonian crisis. Principal concerns included inadequate assessment and documentation in primary care, failure to investigate the low sodium and possible physical causes, insufficient eating-disorder service triage processes, and inadequate information available for the post-mortem examination.

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 understanding of hyponatraemia causes, investigation thresholds and required investigations
Wider context from the report
“5. Lack of understanding of the underlying causes of hyponatraemia (consistently or intermittently low) and the level below which will require further investigation, and the investigations that should be carried out, particularly in circumstances when there is no obvious cause of the low sodium. ”
Source location
Clare Serena Anke COOPER · Prevention of Future Deaths report
Page 3 · 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
Insufficiently clear published guidance on the causes, investigation and treatment of low blood sodium
Wider context from the report
“10. The need to highlight this case nationally to clarify published guidance with regard to the causes, investigation and treatment of low blood sodium and to reinforce the importance of excluding an organic basis of an illness before labelling the condition a psychiatric or psychological disorder. ”
Source location
Clare Serena Anke COOPER · 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
Deliver a Trust-wide academic teaching session for Eating Disorder Service clinical staff on Addison’s disease, hyponatremia, and thresholds for further investigation.

Verbatim wording from the response
“We acknowledge the importance of increasing knowledge and awareness within the Eating Disorder Service about possible causes of hyponatremia and when to seek further investigations. We will be addressing this need through a Trust-wide eating disorders academic meeting during which there will be a teaching session for all clinical staff specifically about presenting symptoms and signs of Addison’s disease including psychological manifestations, causes of hyponatremia and circumstances/levels below which further investigation should actioned.”

Source location
2014-0345-Response-by-Surrey-Borders-Partnership-NHS
Page 2 · response
Published 25 July 2014
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 the BMJ hyponatraemia learning module and record the learning need in professional development plans for appraisal submission.

Verbatim wording from the response
“We have all discussed at length the causes of hyponatraemia and the investigations required to make a diagnosis of Addison’s disease. I am now sure now that all of the doctors here at the practice have a fuller understanding of this rare condition. In addition all of the GPs will now be completing the BMJ online learning e-module on hyponatraemia. We will add this learning need to our PDP’s and will be submitting this for our appraisals. We have also invited ████████ Consultant Endocrinologist at East Surrey Hospital to give a lunchtime educational meeting here at the practice on hyponatraemia and Addison’s Disease. This is provisionally booked for Monday 13th October 2014.”

Source location
2014-0345-Response-by-Woodlands-Surgery
Page 3 · response
Published 25 July 2014
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
Hold a practice educational meeting on hyponatraemia and Addison’s disease with a consultant endocrinologist.

Verbatim wording from the response
“We have all discussed at length the causes of hyponatraemia and the investigations required to make a diagnosis of Addison’s disease. I am now sure now that all of the doctors here at the practice have a fuller understanding of this rare condition. In addition all of the GPs will now be completing the BMJ online learning e-module on hyponatraemia. We will add this learning need to our PDP’s and will be submitting this for our appraisals. We have also invited ████████ Consultant Endocrinologist at East Surrey Hospital to give a lunchtime educational meeting here at the practice on hyponatraemia and Addison’s Disease. This is provisionally booked for Monday 13th October 2014.”

Source location
2014-0345-Response-by-Woodlands-Surgery
Page 3 · response
Published 25 July 2014
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
Advice on concerns relating to hospital medicine should be obtained from hospital medicine rather than the College.

Verbatim wording from the response
“I give below detailed comments on the first six matters of concern you list in this particular case, ie those which directly relate to general practitioner care, setting aside your listed concerns 7 to 10 on which advice from hospital medicine will be more appropriate.”

Source location
2014-0345-Response-by-Royal-College-of-General-Practitioners
Page 2 · response
Published 25 July 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised5

Lack of consultant understanding of appropriate hyponatraemia management

Failure to obtain appropriate specialist assistance for hyponatraemia management

Failure to complete specialist consultation for hyponatraemia management

Failure to follow recommended hyponatraemia monitoring and treatment guidelines

Failure to establish a management plan for hyponatraemia

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.9

Concerns raised2

Lack of understanding of hyponatraemia causes, investigation thresholds and required investigations

Insufficiently clear published guidance on the causes, investigation and treatment of low blood sodium

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.3

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 9

Actions described in response 3

Respondent positions 1