Recurring concern

Unreliable nutrition and hydration safety governance

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First reported 25 Nov 2022•Latest report 28 Nov 2022

Definition

What this concern includes

Includes failures in dedicated nutrition and hydration safety-governance arrangements, including the operation and attendance of a Nutrition and Hydration Committee, nutrition-and-hydration audits, review of compliance, staff learning, action tracking and follow-up of identified deficiencies.

Not included

  • Excludes failures in direct provision, monitoring or recording of patients’ food and fluid intake where no deficiency in nutrition and hydration governance or assurance is identified.
  • Excludes generic committee, audit, learning or management failures not specifically tied to nutrition and hydration safety.
  • Excludes staffing, equipment or care-quality deficiencies that do not concern the dedicated oversight and assurance of nutrition and hydration safety.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2022–2022

First to latest report issue date

Stated actions
2

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Runwood Homes Limited1
Tameside and Glossop Integrated Care NHS Foundation Trust1
Windmill House1

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.

  1. Norfolk

    AI-generated summary

    Janice HOPPER · 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

    Janice HOPPER was discharged from hospital to a care home on 31 December 2021, became unwell in January 2022, was admitted to hospital, and died on 12 February 2022. Concerns included inaccurate and inadequately reviewed care plans, failures to monitor blood glucose, food and fluid intake, and the administration of Morphine Sulphate as a matter of course despite instructions that it was to be given only as required. The inquest recorded the medical cause of death as Alzheimer's Dementia, Chronic Kidney Disease and Type 2 Diabetes Mellitus, with a conclusion of natural causes.

    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 recommended fluids and nutrition auditing and staff lessons-learned processes

    Wider context from the report

    “12. An internal investigation carried out by the Care Home recommended review of Fluids and Nutrition be audited regularly and a "lessons learnt" document would be created for all staff. There is no evidence that these steps have been taken. ”

    Source location

    Janice HOPPER · 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

    Operate a hydration-monitoring system using first-four-week fluid charts, shift-based hydration trolleys, millilitre recording and daily senior review of charts and electronic records.

    Verbatim wording from the response

    “All residents’ care plans are developed with the individual, information gained from the residents’ pre admission assessment and information gained from the resident and their family allows us to gain information regarding what their fluid intake has been like and also through fluid charts for the first four weeks, allows us to monitor fluid intake. Hydration trolleys are in effect at the home, one each shift one person is allocated to be responsible for ensuring that residents’ fluid intake is monitored and documented accurately. This was discussed at the care plan training and how to accurately record fluid intake. All staff are required to ensure that they record intake in millilitres, “mls” in all entries so that the electronic care record system automatically picks up the intake and calculates it.”

    Source location

    Response from Runwood Homes
    Page 2 · response
    Published 1 December 2022

    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

    Communicate lessons learned through flash meetings, staff and care-team-leader meetings, one-to-one sessions, and read-and-sign distribution to the team.

    Verbatim wording from the response

    “Lessons learnt have been completed and reviewed, regular staff and care team leaders meetings have been held to communicate these changes, and also 1:1 supervisions have been held.”

    Source location

    Response from Runwood Homes
    Page 3 · response
    Published 1 December 2022

    Open published response

  2. Manchester South

    AI-generated summary

    Mrs Joan Robinson · 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 Joan Robinson was admitted to hospital after sustaining multiple cervical spinal fractures in a fall at home. During her admission she developed confusion, difficulty swallowing, poor oral intake, atrial fibrillation, congestive cardiac failure and acute kidney injury, and palliative care was instituted. Concerns related to incomplete and non-mandatory training in the Malnutrition Universal Screening Tool and insufficient support, holding or attendance for the Trust’s Nutrition and Hydration Committee.

    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 consistently support, hold and attend the Nutrition and Hydration Committee

    Wider context from the report

    “3. It is a further matter of concern given the importance of adequate nutrition and hydration as a part of basic patient care, that the Trust’s own internal investigation into the care and treatment provided to Mrs Robinson has found that the ‘Nutrition and Hydration Committee [is] not consistently supported, held or attended’. ”

    Source location

    Mrs Joan Robinson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026