17 Dec 2021 Nichola Jane Lomax · Prevention of Future Deaths report Manchester North
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Concerns raised 2
Failure to closely monitor food intake and purging behaviours View source Failure to maintain nutrition and fluid charts View source
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Nichola Jane Lomax · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Nichola Jane Lomax had a long history of an eating disorder and attended hospital several times in 2020 with severe malnutrition and electrolyte imbalance. She died on 3 August 2020 after delays and failings involving hospital treatment, specialist referral, communication, monitoring, nutritional care and access to appropriate services. The report identified concerns about inadequate eating-dis disorder training, access to specialist advice, referral criteria, critical services, community monitoring, nursing care and investigation of deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to closely monitor food intake and purging behaviours
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information.
” Source location Nichola Jane Lomax · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain nutrition and fluid charts
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June . There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information.
” Source location Nichola Jane Lomax · Prevention of Future Deaths report
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3 Dec 2021 TERENCE TALBOT · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Inadequate provision of food and fluid to meet patient needs View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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TERENCE TALBOT · 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
Terence Talbot died at Maidstone & Tunbridge Wells NHS Trust on 9 April 2020 from multiorgan failure due to empyema and pneumonia associated with DRESS Syndrome, following a severe reaction to prescribed medication for bipolar affective disorder. The concerns included repeated discharge and readmission, lack of formal mental-capacity assessments, insufficient dermatology review and emollient application, inadequate food and fluid leading to malnutrition, and issues concerning a requirement to attend in person to claim benefits while severely ill.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate provision of food and fluid to meet patient needs
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” Source location TERENCE TALBOT · Prevention of Future Deaths report
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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 and weekly repeat MUST nutrition screening for all patients to identify deterioration and dietetic intervention needs.
Verbatim wording from the response “▪ All patients continue to have a Malnutrition Universal Screening Tool (MUST) score completed on admission and weekly thereafter to detect any deterioration and ensure dietetic intervention;” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit ward-based therapy assistants to support eating, drinking and speech and language therapy.
Verbatim wording from the response “▪ Ward-based therapy assistants are being recruited. Their focus will also include assisting patients with eating and drinking and speech and language therapy.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen monitoring of inpatient food charts through multidisciplinary discussions with the neighbouring mental health Trust.
Verbatim wording from the response “In order to ensure comprehensive learning from this matter, and as part of the MDT discussions with our neighbouring mental health Trust, the Trust is committed to ensuring further vigilance with regards to the monitoring of food charts for inpatients with physical and mental health needs.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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22 Jul 2021 John Dickinson · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure to create a plan for monitoring fluid and food intake View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
John Dickinson · 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 Dickinson was admitted to hospital after falls and treatment for a gall bladder infection, then moved to a care home. He later developed poor nutritional and fluid intake, dehydration, acute kidney impairment and a urinary tract infection, and died on 9 August 2020 while receiving palliative care. Concerns included inconsistent and insufficiently detailed record keeping, failures to document or act on advice about monitoring food and fluid intake, and delayed recognition of deterioration.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to create a plan for monitoring fluid and food intake
Wider context from the report “(1) The record keeping was inconsistent and lacked detail on general wellbeing.
(2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained.
(3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020.
(4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned.
(5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring.
(6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal.
” Source location John Dickinson · Prevention of Future Deaths report
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5 Feb 2021 Joseph O’Neill · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to provide sufficient prompting and encouragement to maintain hydration View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Care Outlook Ltd
Produce and distribute a dehydration-risk factsheet with recognition, preventive and urgent-response guidance for care workers.
View source
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Joseph O’Neill · 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
Joseph O’Neill developed bronchopneumonia, suffered heat stroke, became dehydrated and died. Concerns included the failure to resolve faulty heating during a heatwave, inadequate rehydration and prompting to drink, and failure to recognise his deterioration.
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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 sufficient prompting and encouragement to maintain hydration
Wider context from the report “He also needed immediate rehydration. When he was admitted to hospital, he was in deficit by about three litres. He was offered a drink by care staff at mealtimes , but he needed constant prompting and encouragement to drink enough .
” Source location Joseph O’Neill · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce and distribute a dehydration-risk factsheet with recognition, preventive and urgent-response guidance for care workers.
Verbatim wording from the response “4. We have also prepared a factsheet providing enhanced guidance for care workers in relation to the risks of dehydration. The factsheet contains practical guidance on how to spot the signs of dehydration, the routine action that can be taken by care workers to prevent this and the urgent action that must be taken when a client is at risk. The fact sheet has been provided to all care workers.” Source location 2021-0030-Response-from-Care-Outlook-Redacted
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5 Nov 2020 Linda Doherty · Prevention of Future Deaths report Surrey
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Concerns raised 1
Failure to properly complete required food charts View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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Linda Doherty · 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
Linda Doherty died in hospital on 7 August 2017 after developing Crohn’s Disease, intestinal failure, malnutrition, sepsis and acute kidney injury. The report identified failures to follow up CT scan findings, recognise and adequately address her nutritional deterioration, and concerns about inaccurate or incomplete nutrition monitoring and the process for placing her on end-of-life care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to properly complete required food charts
Wider context from the report “3. The food charts for Linda Doherty were not completed from 23 June to 12 July 2017 and again from 18 to 23 July 2017 , despite Mrs Doherty being at risk of malnutrition. Consideration should be given as to whether appropriate procedures are in place to (i) identify those patients who require food charts and (ii) to ensure that they are properly completed .
” Source location Linda Doherty · Prevention of Future Deaths report
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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 Record nutrition assessments, care plans, MUST scores, BMI, weight loss, fluid intake and food intake in the Patient Bedside Safety Booklet.
Verbatim wording from the response “At the time of the patient’s admission in 2017, the recording of food charts took place on loose sheets of paper. In August 2018 the ‘Patient Bedside Safety Booklet: Risk assessments and care plans’ was introduced and is now used for all in-patients. This booklet includes all the documentation for nursing assessments, for example falls management, skin integrity and cannula care.” Source location 2020-0224-Response-from-East-Surrey-Hospital-Redacted.pdf
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11 Aug 2020 Moses Victor Boardman · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to properly monitor patients assessed as fed at risk View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Moses Victor Boardman · 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
Moses Victor Boardman, an elderly and frail man, was mistakenly discharged to his home instead of sheltered accommodation, where he was found without heating, light or food and subsequently readmitted to hospital after a further cerebrovascular accident. While assessed as being at risk of aspiration and requiring supervised feeding, he was later found eating a whole fruit unsupervised, suffered a choking incident, and died at 04.48. The substantive concerns included discharge and transport safeguards, failure to escalate missed care visits, monitoring of patients fed at risk, and the response to a potential reversible cause of collapse when a DNACPR order was in place.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to properly monitor patients assessed as fed at risk
Wider context from the report “5. The proper monitoring of patients on RLH ward 14F who have been assessed as being “fed at risk” . Specifically, why was a vulnerable patient left with unsuitable foods within his reach .
” Source location Moses Victor Boardman · Prevention of Future Deaths report
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20 Mar 2020 John Francis GREGORY · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to escalate and respond to prolonged inadequate fluid intake View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to escalate and respond to prolonged inadequate 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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out Restore2 deterioration monitoring, placing records in care plans and requiring monthly nursing updates.
Verbatim wording from the response “To supplement this, since April 2020, Muriel Street has also rolled out the Restore2 deterioration tool (which is based upon the NEWS2 system commonly used across actual hospitals). A copy of the Restore2 documentation is attached and is contained within each resident's care plan file, and updated monthly by a nurse. The Restore tool assists staff members to be able to recognise the early signs that a resident may be deteriorating (as per the Significant 7 course), and then guides nursing staff on appropriate escalation and frequency of monitoring if required to ensure a resident is provided with timely and appropriate medical intervention. It should also be noted that the tool recognises that not all residents are the same, and therefore there is the ability to record additional signs of possible deterioration specific to a resident.” Source location 2020-0073-Response-from-Care-UK_Redacted
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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
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Acute concerns about a resident’s oral fluid intake should be referred to the visiting GP for consideration and advice.
Verbatim wording from the response “at weekly clinical review meetings). Further, in the event of more acute concerns in relation to oral fluid intake, the matter should be raised with the visiting GP to consider and advise, as occurred in Mr Gregory’s case.” Source location 2020-0073-Response-from-Care-UK_Redacted
Open published response
10 Feb 2020 Joan Howard · Prevention of Future Deaths report South Yorkshire (West)
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Concerns raised 2
Delays in displaying nutritional requirements at the bedside View source Failure to provide food consistent with specialist nutritional requirements View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Sheffield Teaching Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Sheffield Teaching Hospitals NHS Foundation Trust
Update, disseminate and make available the ward meal-service SOP covering mealtime safety huddles and dietary requirements.
View source
Sheffield Teaching Hospitals NHS Foundation Trust
Record IDDSI eating, drinking, texture and fluid requirements on the Electronic Whiteboard and populate multidisciplinary handover sheets.
View source
Sheffield Teaching Hospitals NHS Foundation Trust
Provide wards with IDDSI diet signage and related patient information forms, including visible IDDSI level descriptions.
View source
Sheffield Teaching Hospitals NHS Foundation Trust
Add mandatory IDDSI training to Job Specific Essential Training for staff involved in mealtime procedures.
View source
Sheffield Teaching Hospitals NHS Foundation Trust
Implement the finalised Meal Service Safety e-learning package covering IDDSI, the SOP, mealtime safety huddles and hot-food handling.
View source
Sheffield Teaching Hospitals NHS Foundation Trust
Expand the HANAT and Power of 3 audits to monitor IDDSI, SOP and hot-food-handling compliance.
View source
Sheffield Teaching Hospitals NHS Foundation Trust
Mandate the Meal Service Safety e-learning package within the Prepare to Care programme for trainee clinical support workers.
View source
Sheffield Teaching Hospitals NHS Foundation Trust
Maintain Mealtime Safety Huddles as an additional safety barrier for staff involved in mealtimes.
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Joan Howard · 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
Joan Howard was admitted to hospital on 4 April 2019 with specialist dietary requirements and choked to death on 10 April 2019 after being given a sandwich that should not have been provided. The report identified failures to follow dietary guidance and hospital processes, act on information from her care home, provide appropriate fluids, and escalate concerns about inappropriate food. It found that neglect had contributed to her death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in displaying nutritional requirements at the bedside
Wider context from the report “g) Temporary posters for Joan’s nutritional needs were placed above Joan’s bed by staff once they became aware of the need for Joan to have a special diet. This was over 12 hours after her admission to the ward and therefore covered an evening meal, breakfast and lunch, during which inappropriate diet could have been given to Joan and definitely was at lunch time. This was despite information being available to the Ward from the care home Joan had been brought in from about her nutritional requirements. Additionally, the Royal Hallamshire Hospital where she had been discharged from earlier the same day before admission to the Northern General Hospital, had information about her nutritional requirements. It wasn’t until the family noticed that Joan had been given a sandwich at lunch time on 5 April 2019 that staff placed temporary posters above her bed.
” Source location Joan Howard · Prevention of Future Deaths report
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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 consistent with specialist nutritional requirements
Wider context from the report “a) The SALT input into Joan’s care was exemplary. She had appropriate assessments and following a visit on the ward the day after her admission appropriate clear posters were placed above Joan’s bed confirming what nutrition she could have. Despite these posters, on two occasions Joan was provided with inappropriate food.
” Source location Joan Howard · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update, disseminate and make available the ward meal-service SOP covering mealtime safety huddles and dietary requirements.
Verbatim wording from the response “Following the inquest, the SOP (attached) has been updated to include a description of the purpose and approach to the mealtime safety huddle. It has also been updated so that reference is made to specialist advice on patient fluid consistency and special dietary requirements in relation to snack boxes and light bites. The updated SOP is a key component of the e-learning package. It has been shared with matrons, included in the Catering Folder on each ward, and is available to order through the Trust’s ‘Xerox ‘print on demand’ process. Compliance with the SOP will be audited as described above.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record IDDSI eating, drinking, texture and fluid requirements on the Electronic Whiteboard and populate multidisciplinary handover sheets.
Verbatim wording from the response “Work has now been completed to incorporate the national IDDSI descriptors into the Electronic Whiteboard (EWB). This work had already been planned, but was expedited as a result of this incident. As a consequence, patients’ eating and drinking requirements, food texture and fluid consistency are now recorded on EWB. This is a visible prompt to all ward staff (not just nurses) about the patient’s individual requirements. This information then automatically populates the multi-disciplinary handover sheet that is printed from the EWB for ward staff to refer to. The EWB is recognised as a prime Multi-Disciplinary Team handover and effective communication tool within the Trust.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
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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 wards with IDDSI diet signage and related patient information forms, including visible IDDSI level descriptions.
Verbatim wording from the response “For those patients who are admitted to hospital already requiring texture modified diets in the community, the ward teams can now record the information straight onto the EWB and the correct diet signage can be placed above the patient’s bed immediately. The SOP prompts staff to ensure that swallowing assessment detail is placed above the patient’s bed, and wards will now be provided with a supply of signage and related patient information forms so that temporary signage will not be required. Signage is also available to order through the Xerox ‘print on demand’ service and can be downloaded from the Trust intranet site. Signage now also includes a description of the IDDSI levels alongside the level of diet the patient is on, so that this information is clearly visible and easily accessible for staff ‘at a glance’.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
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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 Add mandatory IDDSI training to Job Specific Essential Training for staff involved in mealtime procedures.
Verbatim wording from the response “It is accepted that this approach did not make IDDSI training mandatory, nor could we be sure that every member of staff involved in mealtime procedures (including, for example, housekeepers) had received training in IDDSI through the cascade mechanism. We recognise the need for all staff engaged in mealtime duties to receive training in IDDSI and this will be achieved as outlined below:” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the finalised Meal Service Safety e-learning package covering IDDSI, the SOP, mealtime safety huddles and hot-food handling.
Verbatim wording from the response “• IDDSI training will no longer be delivered by cascade, but through an e-learning package entitled ‘Meal Service Safety’. This approach will ensure consistency, appropriate levels of understanding, and refresher training. The training package will consist of three elements: IDDSI, the Standard Operating Procedure (SOP) which was shared at the inquest and has since been updated (copy attached), and guidance on handling hot food. The training will ensure staff are familiar with IDDSI principles and terminology, and all stages in the SOP. There will be specific focus on the ‘Safety Pause’ which has now been labelled the ‘Mealtime Safety Huddle’ as this is a concept with which nurses are already familiar. The e-learning will also include guidance on handling hot food which, although not an issue in the serious incident, is important in maintaining staff safety.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
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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 Expand the HANAT and Power of 3 audits to monitor IDDSI, SOP and hot-food-handling compliance.
Verbatim wording from the response “• Compliance with IDDSI, including the SOP, will be monitored through two existing audits which will be expanded to include IDDSI compliance. The first audit is the biannual Hydration and Nutrition Assurance Toolkit (HANAT). This has been updated to include specific questions in relation to the SOP and will be reviewed again by the Nutrition Steering Group prior to the next audit to include questions in relation to handling of hot food. The second audit is the annual ‘Power of 3’ audit of meal service, which has been updated to include audit of IDDSI, SOP compliance, and handling of hot food. This audit is undertaken by representatives from catering, dietetics, and senior nursing and involves the completion of an audit of meal service on one ward in each of the care groups annually.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
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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 Mandate the Meal Service Safety e-learning package within the Prepare to Care programme for trainee clinical support workers.
Verbatim wording from the response “• In relation to trainees and students, Trainee CSWs receive their training through our Prepare to Care programme. This includes a nutrition module which covers aspects of nutrition including swallowing, dysphagia and mixing drink thickeners. The training does not currently cover IDDSI, however the new e-learning package will now be mandated as part of the Prepare to Care programme. In the meantime, the SOP and the Mealtime Safety Huddles will include CSWs, along with other staff involved in mealtimes, to support safe mealtime service.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain Mealtime Safety Huddles as an additional safety barrier for staff involved in mealtimes.
Verbatim wording from the response “• In relation to trainees and students, Trainee CSWs receive their training through our Prepare to Care programme. This includes a nutrition module which covers aspects of nutrition including swallowing, dysphagia and mixing drink thickeners. The training does not currently cover IDDSI, however the new e-learning package will now be mandated as part of the Prepare to Care programme. In the meantime, the SOP and the Mealtime Safety Huddles will include CSWs, along with other staff involved in mealtimes, to support safe mealtime service.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
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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 COVID-19 operational pressures prevent implementing all planned safety changes in the near future.
Verbatim wording from the response “Having outlined the actions we have agreed to take in response to this incident and to the PFD Report, I hope that I have been able to convey how seriously we have viewed this matter. Whilst we will be unable to implement all these changes in the near future, given the urgency of the situation in relation to COVID-19, we are absolutely committed to learning from Mrs Howard’s death and implementing the remaining actions at the earliest opportunity.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
Open published response
Concerns raised 1
Inadequate management oversight of staff deployment for residents requiring choking-risk or one-to-one food and fluid assistance View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Coed Duon
Provide trained mealtime staff in the dining room to oversee dysphagia-trained staff assisting residents at choking risk.
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Coed Duon
Provide a registered general nurse in the dining room throughout mealtimes.
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AI-generated summary
Kathleen 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
Kathleen Smith, who had advanced dementia and was at risk of choking, died after being fed unsuitable food and aspirating. The report raised concerns about inadequate staff training, failure to assist during the choking emergency, poor communication, and insufficient management oversight of safe food and fluid care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate management oversight of staff deployment for residents requiring choking-risk or one-to-one food and fluid assistance
Wider context from the report “1. Staff were not sufficiently trained in first aid or how to assist a resident who was at risk of choking.
2. Staff did not intervene to assist the resident for whom the internal emergency alarm had been sounded as help was needed.
3. Staff were not sufficiently trained in how to select and prepare correct foods and fluids for residents with special dietary needs and who had a documented risk of choking.
4. The above training remains incomplete approximately 11 months after the death of Mrs Smith.
5. Staff could not demonstrate they understood how to deliver safe care and treatment regarding food and fluids and manage the risk of choking.
6. There is no adequate management oversight to ensure staff are appropriately deployed to those residents at risk of choking and or who require one to one assistance with food and fluids.
” Source location Kathleen Smith · Prevention of Future Deaths report
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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 trained mealtime staff in the dining room to oversee dysphagia-trained staff assisting residents at choking risk.
Verbatim wording from the response “5. There is a trained member of staff on duty in the dining room during mealtimes to oversee the appropriately trained staff in Dysphagia to assist the residents at risk of choking. Also staff now write on diet & fluid charts what daily meals are served and they are clearer on what they have eaten, for example. puree mashed potatoes, puree, instead of Mash, Veg chicken” Source location 2019-0184-Response-by-Coed-Duon-Care-Home
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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 a registered general nurse in the dining room throughout mealtimes.
Verbatim wording from the response “6. There is always an RGN in the dining room during mealtimes.” Source location 2019-0184-Response-by-Coed-Duon-Care-Home
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A registered general nurse is always present in the dining room during mealtimes.
Verbatim wording from the response “6. There is always an RGN in the dining room during mealtimes.” Source location 2019-0184-Response-by-Coed-Duon-Care-Home
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Concerns raised 1
Failure to ensure accurate recording of patients’ nutritional intake View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Sheila Graham · 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
Sheila Graham was admitted to hospital after a fall causing a complicated ankle fracture, subsequently developed infection and clostridium difficile, and died on 13 October 2017 after an upper gastrointestinal bleed. Concerns included the effects of prolonged isolation on her mental and general wellbeing, inadequate recording and monitoring of nutrition despite weight loss, and delayed referral to mental health and dietetic services.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure accurate recording of patients’ nutritional intake
Wider context from the report “(2) There was evidence that meals were delivered by an independent company called Sodex. The family frequently observed this company giving out and collecting meal trays. Despite this medical records appeared to have been completed daily by nursing and health care staff recording adequate nutrition. Given this situation how is it possible to reconcile the nursing records with the practice of the catering team distributing and collecting meal trays?
” Source location Sheila Graham · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.