Case Study: How a Nursing Fluid Balance Expert Witness Reviewed IV Hydration Failures in an End-of-Life Admission

When poor fluid charting undermines care quality, safety and defensibility

In this case, a terminally ill patient with known swallowing issues and significant comorbidities was admitted for symptom management and observation. Throughout the admission, the patient remained nil by mouth due to risk of aspiration. Despite this, IV fluids were inconsistently administered, fluid balance was not charted, and hydration status was poorly tracked. Several observations indicating deterioration, including hypotension and fever, went unrecorded or undocumented on electronic systems.

An Apex nursing fluid balance expert witness was asked to examine whether the hydration-related care met a reasonable standard. The expert found multiple breaches, concluding that the failure to maintain accurate input/output records, delayed cannula replacement, and IV fluid omissions likely compromised the patient’s condition.

What the nursing fluid balance expert witness identified in fluid administration and observation gaps

A detailed nursing review highlighted critical failings in basic hydration care:

• The patient was nil by mouth for several days, but no structured IV fluid plan was documented

• Fluid balance charts were missing or incomplete, preventing review of hydration status

• Prescribed infusions were delayed or undocumented, and timing gaps between bags exceeded safe windows

• No documentation confirmed the total volume received throughout admission

• A failed cannula was left unreplaced for hours, during which IV antibiotics and hydration were withheld

• A key drop in blood pressure was recorded manually but never uploaded to the digital system

“When a patient is nil by mouth, IV fluid becomes their lifeline. Not tracking it properly is not just a documentation issue, it’s a patient safety failure.”— Apex Nursing Fluid Balance Expert Witness

What a nursing fluid balance expert witness expects in high-risk, nil by mouth admissions

Patients unable to hydrate orally require meticulous IV fluid management and documentation. A nursing expert in fluid balance would expect:

1. Accurate, continuous fluid input/output charts throughout the admission

2. Fluid prescriptions actioned within clinically safe timeframes

3. Escalation when cannula issues threaten essential IV access

4. A nursing care plan outlining hydration goals and review timings

5. Coordination with medical staff when infusion plans are delayed or disrupted

In this case, the absence of reliable records, combined with physical deterioration and family concern, left little defensible evidence of quality hydration care.

Escalation failures added further risk

In addition to fluid balance failures, observations indicating deterioration were not actioned appropriately. A critically low blood pressure reading was reported manually, but the patient was not reviewed by medical staff. The charting system contained no record of this critical observation, nor was there evidence of follow-up. At the time, the patient was due for IV antibiotics and potassium replacement both of which were missed due to lack of IV access.

The expert found that the patient was not escalated, not monitored, and not hydrated to an acceptable standard during her final 48 hours. While causation requires physician review, the nursing failings were substantial.