Recurring concern

Inadequate management of patients' nutrition and hydration needs

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First reported 2 Jul 2014•Latest report 24 Feb 2026

Definition

What this concern includes

Includes failures of controls specifically dedicated to assessing, monitoring, recording, providing or reviewing patients' food and fluid intake and nutritional or hydration needs, including risk assessments, nutrition or fluid charts, prompting, prescribed nutritional support and escalation of inadequate intake.

Not included

Excludes medication, electrolyte or disease-specific treatment concerns unless the asserted deficiency directly concerns nutrition or hydration needs.
Excludes generic clinical record-keeping, staffing or care-planning deficiencies unless they directly impair the nutrition and hydration process.
Excludes food-service or dietary provision failures where no patient-specific nutrition or hydration safety need is identified.
Excludes malnutrition-only concerns that do not materially involve the broader nutrition and hydration management process.
Excludes isolated fluid-balance recording failures where the concern is limited to fluid records and does not support the wider nutrition and hydration condition.

Reports: 39
Individual concerns: 44
Date range: 2014–2026
Stated actions: 80

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.

Care Quality Commission5

Department of Health and Social Care3

East Sussex Healthcare NHS Trust2

University Hospitals Sussex NHS Foundation Trust2

A & B Healthcare Limited1

Academy of Medical Royal Colleges1

Amberley Hall Care Home1

Aneurin Bevan University LHB1

Athena Care Homes (UK) Limited1

Barts Health NHS Trust1

Cardinal HC Limited1

Care Outlook Ltd1

Care UK1

Care UK Community Partnerships Ltd1

Caring UK Limited1

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.

3 Oct2018
West Yorkshire Eastern
Concerns raised1
1. Failure to maintain contemporaneous nursing records of food and fluid intake
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 2
1. Action
  Address inconsistent nutrition and hydration record-keeping with the ward team and discuss it subsequently.
  Stated by Leeds Teaching Hospitals NHS TrustStated completed
2. Action
  Complete Healthcheck auditing of ward J83 nutrition and hydration documentation and care standards.
  Stated by Leeds Teaching Hospitals NHS TrustStated completed
AI-generated summary

Theresa Maria BUTTON · 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

Theresa Maria BUTTON underwent a liver transplant, remained in hospital for approximately 15 weeks, suffered multiple complications including a stroke, developed pneumonia, and died on 7 December 2017. Concerns included staffing levels and whether limited nursing capacity affected implementation of treatment plans, nutritional care, communication with family members, and contemporaneous record-keeping.

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 contemporaneous nursing records of food and fluid intake
Wider context from the report
“5. Contemporaneous nursing records were not always maintained; for example relating to food and fluid intake (even though nutrition was a matter of concern to the treating clinicians). ”
Source location
Theresa Maria BUTTON · 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
Address inconsistent nutrition and hydration record-keeping with the ward team and discuss it subsequently.

Verbatim wording from the response
“Prior to, and during the course of the inquest ████████ apologised that record keeping in relation to nutrition and hydration was not to a consistently high standard. This was addressed with the ward team at the time and has been discussed subsequently.”

Source location
2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Page 4 · response
Published 1 March 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
Complete Healthcheck auditing of ward J83 nutrition and hydration documentation and care standards.

Verbatim wording from the response
“The Trust has in place an audit process referred to as the ward/department Healthcheck. This provides a systematic overview of performance across a range of key areas that influence or reflect the standards of care, patient outcomes and experience of care delivered in the Trust. The data can be viewed at organisational, CSU and ward level, providing both a local and strategic picture. A copy of the completed Healthcheck for ward J83 over a 12 months period in relation to nutrition and hydration has been included with this letter. You will note that the ward results demonstrate a very high level of compliance across the key areas identified.”

Source location
2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Page 5 · response
Published 1 March 2019
Open published response
3 Apr2018
Manchester South
Concerns raised1
1. Provision of food unsuitable for a soft diet
This report raised 1 other concern. 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

Barbara Haley · 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

Barbara Haley inhaled vomit, saliva, food or liquid while resident at Hilltop Court Care Home, developed a chest infection, and died at Stepping Hill Hospital on 13 October 2017 after suffering a cardiac arrest en route. Concerns included her being provided food unsuitable for her soft diet and being left alone to eat despite having been assessed as at high risk of choking.

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
Provision of food unsuitable for a soft diet
Wider context from the report
“1. Mrs Haley was on a soft diet (described as a “fork-mashable diet” in evidence). Despite this, there was evidence that Mrs Haley had been provided with food items not suitable for her by staff. In particular, on one occasion toast was found in her room. On another occasion, staff had apparently suggested to a family member that chocolate could be given to Mrs Haley. ”
Source location
Barbara Haley · Prevention of Future Deaths report
Page 1 · concerns
Open source report
19 Oct2017
Surrey
Concerns raised1
1. Failure to implement prescribed nutritional advice
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.

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

June Evelyn Evans · 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

June Evelyn Evans was admitted to St Peter’s Hospital with diarrhoea and was assessed as being at high risk of pressure sores. She developed a severe hospital-acquired pressure sore that became infected, and she died of sepsis on 1 July 2016. The principal concerns were failures to prevent and promptly refer and treat the pressure sore, inadequate nutrition, clinicians’ delayed awareness of the sore, and understaffing across the wards.

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 implement prescribed nutritional advice
Wider context from the report
“3. Dietician’s advice in respect of the quantity of nutrition required by Mrs Evans was not implemented by the nursing staff. Naso- gastric feeding was advised by both the treating doctor and the dietician on the 14th June 2016. This advice was not followed and there was no evidence of why this did not occur. Mrs Evans was not provided with adequate nutrition. ”
Source location
June Evelyn Evans · Prevention of Future Deaths report
Page 2 · concerns
Open source report
29 Apr2016
Brighton and Hove
Concerns raised1
1. Failure to monitor nutritional status and refer for dietary support
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.

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

Jack MOLYNEUX · 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

Jack MOLYNEUX was awaiting discharge to a nursing home after admission to a ward for elderly male patients, where he had dementia but no acute physical illness. The report describes concerns about inadequate care, including failures relating to mobility, hydration, nutrition, mouth care, personal hygiene, psychological wellbeing, stimulation and medication, and states that these omissions and failings contributed to his death. His death was unexpected after transfer to the nursing home, where his condition and engagement reportedly improved.

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 monitor nutritional status and refer for dietary support
Wider context from the report
“Mr Jack MOLYNEUX was awaiting discharge to an appropriate Nursing Home. He was on a 19 bedded ward for elderly male patients and during that time he was not suffering from any acute physical illness, but he did however have moderately advanced mixed alzheimer’s and vascular dementia and he needed to be mobilised, he needed to be appropriately hydrated and have his nutrition maintained. He needed mouth care, he had dentures but the top plate was lost. He needed personal hygiene, he needed to have his psychological wellbeing maintained and he needed stimulation and he also needed to have his medications given to him appropriately. It was clear that he did not have mental capacity, it was clear that he could not consider the consequences of his decisions not to accept care or hydration and nutrition or his medications and yet no consideration was given of placing him on a Deprivation of Liberty Safeguarding Order. He needed, but he didn’t receive full care in respect of all the matters mentioned above. Mobility He was never helped to mobilise or to maintain the good mobility which he had when he came into hospital. He was never offered to have his out door clothes and perhaps to be assisted to go down to the hospital shop to buy a newspaper which was something he used to do every day before he came into hospital. He lost 20% of his bodyweight in the one calendar month when he was in hospital and absolutely no note was taken of this and he wasn’t referred to the dieticians until he had been in hospital for almost that full calendar month. His mouth was in such an appalling state when he moved to his nursing home that the nursing home immediately raised a safeguarding alert on the grounds of neglect. His dentures were lost and his mouth was in such a poor state that the staff, on Vallance Ward, were unaware that he even had a lower plate in his mouth. His personal hygiene was such that whilst it was noted he was washed there was no evidence whatsoever that he was ever offered a bath or shower in the four weeks of his admission. There was no evidence whatsoever that any form of stimulation was provided. There was a television by his bed but no evidence that anybody ever discussed with him whether he might like to watch anything on it. With regard to his psychological wellbeing this appeared from the evidence before me to have been completely disregarded. Finally with regard to his medications he refused all his medications on an inconsistent basis but he did take his Memantine for pretty well every day of his hospital admission apart from on a couple of occasions just before he was discharged. At the Inquest I found that whilst he had been neglected during his admission, the circumstances did not reach the required standards for a conclusion of neglect contributing his death. I believe this to be one of the most disturbing cases of sub optimal care that I have come across recently and I am not at all satisfied that this Inquest will result in any effective action being taken which is why I am concerned to follow up this matter and to ensure that all those who should know about this situation are informed. Certainly I found that the above omissions and failings contributed to Mr Molyneux’s death. When he arrived at the nursing home he came on the evening of the 25th January and on the 26th the staff at Partridge House achieved an almost miraculous transformation. He was dressed, although he needed the help of two members of staff, he was on his feet and assisted to mobilise to the toilet, he was sitting out in a bucket chair with other residents and was entertained with a film, his mouth was cleaned, the GP provided mouth wash and mouth gel which was applied. His halitosis which had been so strong that it could be smelt outside his room at Partridge House was resolved, he was smiling and reasonably responsive and was eating and drinking again and also engaged with his son, waving goodbye to him when he had visited on the 26th or 27th. His death was unexpected. Partridge House staff had hoped that whilst he would not have been able to go home he could at least have a reasonable standard of life and be enabled to be content. Finally, it is of note that an urgent DOLS was put in place on the morning of the 27th January 2016. ”
Source location
Jack MOLYNEUX · Prevention of Future Deaths report
Page 2 · concerns
Open source report
14 Sep2015
Stoke-on-Trent and North Staffordshire
Concerns raised1
1. Failure of staff to appreciate the importance of prescribed nutritional supplements
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.
Respondent positions 1
1. Position
  Issues arising after the hospital return were not notified to the City Council, so they were not investigated by it.
  Stated by Stoke-on-Trent City CouncilUnable to act
AI-generated summary

Janine Eugenie Pierrette KAISER · 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

Janine Eugenie Pierrette KAISER died at a nursing home on 21 October 2014 from lobar pneumonia, with suppurative cystitis, a sacral pressure ulcer, aortic stenosis, multiple myeloma and stroke also recorded. The principal concerns included missed turns, inaccurate or falsified records, inadequate pressure-mattress checks, poor recording of food and fluid intake, inadequate staff training and continuity, delayed referral to tissue viability nurses, and insufficient response to weight loss and safeguarding concerns. The inquest concluded that she died from significant natural disease, with a contributing sacral ulcer whose progress had been compromised by gaps in nursing care.

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 staff to appreciate the importance of prescribed nutritional supplements
Wider context from the report
“7. The deceased had lost a considerable amount of weight but there was no referral to a dietician (although the GP had been consulted regarding her weight loss and had prescribed supplements) The importance of the supplements was not fully appreciated by all of the staff. The deceased’s weight was maintained during a hospital stay but deteriorated on her return to New Park Nursing Home ”
Source location
Janine Eugenie Pierrette KAISER · 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
Issues arising after the hospital return were not notified to the City Council, so they were not investigated by it.

Verbatim wording from the response
“5. Twice daily pressure mattress checks were fully completed indicating an appropriately functioning mattress. However when a mattress check was made by Tissue Viability Nurses the mattress was not alternating and the fault alarm on the mattress had been turned off. The attention of the staff was drawn to this but it was not subsequently recorded in the deceased’s records. The staff were inadequately trained in pressure mattress management. They apparently checked that the mattress had a power source but did not check that the mattress was functioning correctly.”

Source location
2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
Page 4 · response
Published 14 July 2015
Open published response
7 May2015
Brighton and Hove
Concerns raised1
1. Failure to record food intake
This report raised 24 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
  Monitor documentation more closely and provide nurses with real-time feedback.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
2. Action
  Review and condense Acute Medical Unit documentation into multidisciplinary paperwork that directs care and reduces duplication.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
AI-generated summary

Mrs. Evelyn KENNEDY · 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. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.

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 food intake
Wider context from the report
“(1) Once again my concerns involve the Acute Medical Unit (AMU). (2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. (4) She arrived unkempt. (5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care. (6) She felt cold and said she was cold. (7) She had been incontinent of faeces and had not been cleaned for some time. (8) She had no name wrist band. (9) In spite of known allergies she had no allergy wrist band. (10) In spite of falling regularly she had no falls risk wrist band. (11) She still had an IV cannula in place; this should have been removed after 72 hours. (12) Her daily catheter care bundle had not been completed for 3 days. (13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th. (14) Care plans were not completed for 17th, 18th, 19th or 20th. (15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th. (16) The handling assessment was not completed for 16th, 18th, 19th or 20th. (17) No food chart was completed for her entire time in AMU. (18) She had pressure damage to her hips and bottom. (19) No daily oral assessment was completed for her entire time on AMU. (20) She was not weighed. (21) The malnutrition tool was not completed. (22) Her bowel movements were not recorded. (24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart. PLUS (25) No personal care over the weekend of 18th and 19th. (26) No senior review over that weekend. (27) Not written up for her Sertraline, therefore not given (28) Not written up for any food supplements until 21st October. (29) She should have been specialled, but wasn’t. Once again AMU has been found to be chaotic and not fit for purpose. ”
Source location
Mrs. Evelyn KENNEDY · 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
Monitor documentation more closely and provide nurses with real-time feedback.

Verbatim wording from the response
“Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:”

Source location
2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 7 May 2015
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 condense Acute Medical Unit documentation into multidisciplinary paperwork that directs care and reduces duplication.

Verbatim wording from the response
“Extensive and complex work is also being undertaken to”

Source location
2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 3 · response
Published 7 May 2015
Open published response
17 Nov2014
West Yorkshire (East)
Concerns raised1
1. Failure to implement nutrition charts for residents with significant weight loss
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

Mrs Gladys Smith · 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 Gladys Smith died while resident at a care home; the supplied text does not provide further circumstances of her death. The concerns included failures in repositioning, bruise and wound monitoring, falls assessment, weight and nutrition monitoring, dementia care, and delays or gaps in district nursing wound documentation and referral. The report also identified a lack of comprehensive national guidance on wounds and ulcers caused by impact injuries.

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 implement nutrition charts for residents with significant weight loss
Wider context from the report
“(f) Despite the aforesaid weight loss experienced by Mrs Smith, at no time was a nutrition chart implemented in order to monitor Mrs Smith's nutritional intake. Moreover, medical advice in relation to Mrs Smith's weight loss was only sought a number of weeks after the commencement of the said weight loss. In the circumstances, Care Home staff should ensure nutrition charts are completed in respect of any resident whose weight falls significantly and should ensure appropriate medical advice is sought at the first available opportunity following such a fall in weight; ”
Source location
Mrs Gladys Smith · Prevention of Future Deaths report
Page 1 · concerns
Open source report
27 Oct2014
Manchester South
Concerns raised1
1. Failure to monitor intravenous cannula connections and hydration delivery
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 1
1. Action
  Train nursing staff to secure cannulas and check for detachment or fluid loss during bedside attendance.
  Stated by Tameside General HospitalStated completed
AI-generated summary

Agnes Mary Hannan · 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

Agnes Mary Hannan, who had autoimmune hepatitis with cirrhosis, attended Tameside General Hospital several times with severe abdominal pain before being admitted. She was diagnosed with Superior Mesenteric Vein Thrombosis causing bowel infarction and died on 21 September 2013. The report identified concerns about delayed diagnosis, inadequate monitoring and hydration, poor communication and handover, incomplete records, lack of multidisciplinary involvement, and insufficient communication with her family about her condition and end-of-life care.

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 monitor intravenous cannula connections and hydration delivery
Wider context from the report
“2. On one occasion whilst she was an in-patient, Mrs Hannan who was desperately ill and needing intra-venous hydration, was found to be lying in a soaking wet bed because the tube leading to her cannula had become dislodged and disconnected. The nursing staff had failed to notice this problem. The doctors in evidence, acknowledged that her lack of hydration would inevitably have worsened her already thrombosed veins. ”
Source location
Agnes Mary Hannan · 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
Train nursing staff to secure cannulas and check for detachment or fluid loss during bedside attendance.

Verbatim wording from the response
“Response The Trust’s nursing staff are trained to carefully insert and tape cannulas to the skin to minimise the risk of them becoming loose, disconnected or falling out. Unfortunately, despite taping them down cannulas do, on occasions, become loose, for example, if patients inadvertently dislodge them. If a cannula becomes dislodged patients may alert nursing staff so that it can be re-secured to prevent the loss of fluid. We appreciate that on occasions patients are not aware or are not well enough to alert nursing staff themselves. If that occurs our staff should become aware that there is a detached cannula and/or loss of fluid on next attending at the patient’s bedside.”

Source location
2014-0573-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 27 October 2014
Open published response
2 Jul2014
Manchester South
Concerns raised1
1. Failure to provide food and fluid during prolonged care periods
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.

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

ALBERT 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

Albert Flynn, a resident of Appleton Manor Residential Home, was taken to hospital with a suspected deep vein thrombosis and treated with the blood-thinning drug Enoxaparin. The following night he was left in a chair for approximately 10 hours without food, fluids or prescribed medication, while staff were unable to rouse him. He was suffering from a severe cerebral bleed, which was fatal; concerns included inadequate staff training and failure to recognise the significance of his condition and recent blood-thinning 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 provide food and fluid during prolonged care periods
Wider context from the report
“1. Whilst the care staff members were apparently concerned as to the condition of Mr Flynn, none of them was sufficiently well trained or qualified to make an informed decision as to how he should be treated. 2. As a result of the above, he was left sitting in a chair, partially dressed, without food, fluid or medication for a period of approximately 10 hours. 3. None of the staff gave any indication of any, or any proper, training in the assessment of this type of event, nor did they attribute any or any sufficient weight to the fact that he had been administered blood thinning drugs the previous day. 4. The staff did not seem to appreciate the importance of administering prescribed medication. ”
Source location
ALBERT FLYNN · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to maintain contemporaneous nursing records of food and fluid intake

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

Concerns raised1

Provision of food unsuitable for a soft diet

Concerns raised1

Failure to implement prescribed nutritional advice

Concerns raised1

Failure to monitor nutritional status and refer for dietary support

Concerns raised1

Failure of staff to appreciate the importance of prescribed nutritional supplements

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 food intake

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

Concerns raised1

Failure to implement nutrition charts for residents with significant weight loss

Concerns raised1

Failure to monitor intravenous cannula connections and hydration delivery

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 provide food and fluid during prolonged care periods

Actions described in response 2

Respondent positions 1

Actions described in response 2

Actions described in response 1