Recurring concern

Insufficient dietetic staffing capacity for timely patient care

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First reported 6 Nov 2018•Latest report 3 Jun 2024

Definition

What this concern includes

Includes recurring deficiencies in dietetic staffing numbers, skill mix, recruitment, retention, deployment or cover where they delay dietetic assessment, leave dietetic needs unmet or prevent required weekday, weekend or out-of-hours dietetic provision.

Not included

  • Excludes general healthcare staffing shortages where dietetic staffing or dietetic care is not the identified unsafe condition.
  • Excludes failures in dietetic assessment quality, referral, communication or treatment where staffing capacity is not the shared cause or condition.
  • Excludes shortages in other specialist services, including radiology, mental health, nursing or social care, unless the assertion explicitly concerns dietetic staffing capacity.
  • Excludes isolated staff absence or a single missed assessment where no continuing dietetic staffing-capacity deficiency is asserted.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2018–2024

First to latest report issue date

Stated actions
19

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.

Frimley Health NHS Foundation Trust1
Frimley Park Hospital1
Glangwili General Hospital1
Stockport NHS Foundation Trust1

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. Surrey

    AI-generated summary

    Isabella MCCREADIE · 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

    Isabella McCreadie, aged 90, suffered a fall at home causing fractures, was admitted to hospital and underwent surgery. She developed low haemoglobin, delirium and a hospital-acquired stage 4 pressure sore, and died of pneumonia at home on 6 June 2023. Concerns included insufficient dietetic staffing, pressure-sore care and training, an unprocessed dietary supplement order, and inadequate training for some agency staff using the hospital’s computer system.

    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

    Insufficient staffing in the dietetics department to address patients' dietetic needs

    Wider context from the report

    “1. In evidence I was advised during Mrs McCreadie's stay in hospital her dietetic needs were not addressed as there was insufficient staffing in the dietician department. I asked the hospital when giving evidence if these issues had been addressed and was advised that there were still ongoing. I am concerned that if appropriate staffing levels are not put in place, patient's needs will not be met. ”

    Source location

    Isabella MCCREADIE · 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

    Review therapy directorate demand and capacity and compile a dietetics staffing proposal.

    Verbatim wording from the response

    “A review is currently being undertaken to look at demand and capacity for the whole of the therapy’s directorate including the dietetics team and a staffing proposal paper is being compiled. The Trust seeks to reassure you that resources in the dietetics team are being used as effectively as possible to ensure patient’s needs are appropriately met and bank work is being offered where appropriate.”

    Source location

    Response from Frimley NHS
    Page 1 · response
    Published 6 June 2024

    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

    Move dietetics resource from Wexham Park Hospital to Frimley Park Hospital to meet higher acute-team demand.

    Verbatim wording from the response

    “Earlier this year, some resource was moved from the Wexham Park Hospital dietetics team to Frimley Park Hospital to meet the higher demand in the acute team at Frimley Park Hospital.”

    Source location

    Response from Frimley NHS
    Page 1 · response
    Published 6 June 2024

    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

    Participate in the national dietetics staffing benchmarking programme and submit Trust data.

    Verbatim wording from the response

    “The Trust has engaged with a national benchmarking programme which is being managed by the British Dietetic Association who feel that the current national safe staffing guidance for dietetics needs to be updated. This is based on the fact that 55% of respondents to the British Dietetic Association questionnaire felt there was unsafe staffing within their dietetics team. We feel that this illustrates that resourcing for dietetics is a national issue.”

    Source location

    Response from Frimley NHS
    Page 1 · response
    Published 6 June 2024

    Open published response
  2. Manchester South

    AI-generated summary

    LESLEY MAWBY · 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

    Lesley Mawby, who had multiple myeloma, developed severe vomiting and diarrhoea after starting chemotherapy and was admitted to hospital. She subsequently experienced malnutrition, electrolyte disturbances, sepsis and upper gastrointestinal haemorrhage, and died from multi-organ failure on 5 October 2020. The report raised concern about staffing shortages in the dietetic team causing delays in assessments and lack of weekend cover.

    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

    Residual staffing shortages in the dietetic team

    Wider context from the report

    “(1) It is a matter of concern that there are residual staffing shortages in the dietetic team leading to delays in assessments on weekdays and meaning weekend cover cannot be provided. ”

    Source location

    LESLEY MAWBY · 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

    Conduct twice-daily senior-dietitian triage and prioritise referrals using referral criteria and clinical judgement.

    Verbatim wording from the response

    “Twice daily triage There is twice daily triage by a senior dietitian. All referrals for new patients are triaged by the Dietitians and prioritised according to the dietetic referral triaging criteria, ‘The Inpatient ward referral triage criteria’ (Appendix A), details the target times for reviewing referred patients in line with priority category. However, the Dietitians review all referrals in full and use clinical judgement to review a patient sooner if necessary.”

    Source location

    2021-0208-Response-from-Stepping-Hill-Hospital_Published
    Page 1 · response
    Published 28 June 2021

    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

    Provide weekend out-of-hours enteral and parenteral feeding guidance to ensure patients receive appropriate nutrition pending dietetic review.

    Verbatim wording from the response

    “7 day provision The service is not commissioned to run over 7 days and this is in line with other Greater Manchester NHS Trusts. The target times for reviewing patients are in line with priority categories. However, there is weekend provision currently in place in the form of out of hours guidance, available for all staff, which includes feeding regimes for patients on enteral feeding or parenteral feeding: this supports appropriate nutrition being available over weekends ensuring no delays. A copy is attached in Appendix B and C. The subsequent”

    Source location

    2021-0208-Response-from-Stepping-Hill-Hospital_Published
    Page 1 · response
    Published 28 June 2021

    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

    Use a streamlined referral spreadsheet recording assessment due dates, follow-up review dates and review reasons.

    Verbatim wording from the response

    “Improved process A new streamlined process has been implemented, where staff add the referrals to a spreadsheet with ‘assessment due date’ documented based on assessment criteria. This new process allows staff to filter the data easily and has improved ways of working. Patients already seen and requiring follow up remain on the spreadsheet with a ‘review date’ documented and reason for review.”

    Source location

    2021-0208-Response-from-Stepping-Hill-Hospital_Published
    Page 2 · response
    Published 28 June 2021

    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

    Allocate highest-priority new and follow-up patients to available staff under senior-dietitian oversight.

    Verbatim wording from the response

    “The Dietitian will review the highest priority patients from new and follow up patients and allocate those patients in order based on the criteria and clinical judgement to the staff available. The process is overseen by a senior Dietitian.”

    Source location

    2021-0208-Response-from-Stepping-Hill-Hospital_Published
    Page 2 · response
    Published 28 June 2021

    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 dietetic staffing risks monthly through divisional governance and the Risk Management Committee.

    Verbatim wording from the response

    “Business Case developed – Therapies Staffing A risk assessment in respect of the dietetic staffing was completed in October 2020 and a detailed review has been completed. The risk to patients due to the staffing establishment and capacity in the team is reviewed monthly by the divisional team and by the executives at the Risk Management Committee.”

    Source location

    2021-0208-Response-from-Stepping-Hill-Hospital_Published
    Page 2 · response
    Published 28 June 2021

    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 and progress a business case for increased nutrition and dietetic staffing through Trust governance.

    Verbatim wording from the response

    “A business case for therapy staffing is under development and is progressing through the Trust governance process. The Business Case is for increased support for therapy provision regarding nutrition and dietetics. It provides an option appraisal with a phased implementation of both qualified and non-qualified workforce, identifying high risk areas and allowing for training opportunities. However, the Trust has recognised the need for additional resource and is already recruiting to the posts. We would be happy to update you on progress in the future, if required.”

    Source location

    2021-0208-Response-from-Stepping-Hill-Hospital_Published
    Page 2 · response
    Published 28 June 2021

    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

    Recruit to additional nutrition and dietetic posts to address identified staffing needs.

    Verbatim wording from the response

    “A business case for therapy staffing is under development and is progressing through the Trust governance process. The Business Case is for increased support for therapy provision regarding nutrition and dietetics. It provides an option appraisal with a phased implementation of both qualified and non-qualified workforce, identifying high risk areas and allowing for training opportunities. However, the Trust has recognised the need for additional resource and is already recruiting to the posts. We would be happy to update you on progress in the future, if required.”

    Source location

    2021-0208-Response-from-Stepping-Hill-Hospital_Published
    Page 2 · response
    Published 28 June 2021

    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 a dietitian job-planning exercise and benchmark staffing against British Dietetic Association recommendations.

    Verbatim wording from the response

    “Job planning and benchmarking There is a dietitian job planning exercise underway with Project Management Office (PMO) support, due for completion in September 2021. This will be benchmarked against the British Dietetic Association (BDA) Dietetic Caseload Recommendations. The service is also participating in an NHS benchmarking exercise. A task and finish group has been set up to review processes and identify improvements. In addition, the service is benchmarking the referral process with other Greater Manchester trusts and there is an ongoing review of ward care plans /referral criteria. The current skill mix is also in the process of review with the roles and responsibilities of non-registered staff being examined.”

    Source location

    2021-0208-Response-from-Stepping-Hill-Hospital_Published
    Page 2 · response
    Published 28 June 2021

    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 skill mix and examine non-registered staff roles and responsibilities.

    Verbatim wording from the response

    “Job planning and benchmarking There is a dietitian job planning exercise underway with Project Management Office (PMO) support, due for completion in September 2021. This will be benchmarked against the British Dietetic Association (BDA) Dietetic Caseload Recommendations. The service is also participating in an NHS benchmarking exercise. A task and finish group has been set up to review processes and identify improvements. In addition, the service is benchmarking the referral process with other Greater Manchester trusts and there is an ongoing review of ward care plans /referral criteria. The current skill mix is also in the process of review with the roles and responsibilities of non-registered staff being examined.”

    Source location

    2021-0208-Response-from-Stepping-Hill-Hospital_Published
    Page 2 · response
    Published 28 June 2021

    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

    Combine community and acute nutrition and dietetic staffing establishments to enable flexible cross-service working.

    Verbatim wording from the response

    “Additional measures implemented by the Dietetic Service to mitigate the risk are as follows:”

    Source location

    2021-0208-Response-from-Stepping-Hill-Hospital_Published
    Page 2 · response
    Published 28 June 2021

    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

    Combine specialist acute caseloads and prioritise them across the service.

    Verbatim wording from the response

    “Additional measures implemented by the Dietetic Service to mitigate the risk are as follows:”

    Source location

    2021-0208-Response-from-Stepping-Hill-Hospital_Published
    Page 2 · response
    Published 28 June 2021

    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

    Monitor caseloads regularly to ensure patients are prioritised and seen within appropriate timescales.

    Verbatim wording from the response

    “• Caseload management monitored regularly to ensure patients are prioritised and seen in a timely manner.”

    Source location

    2021-0208-Response-from-Stepping-Hill-Hospital_Published
    Page 2 · response
    Published 28 June 2021

    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

    The dietetic service cannot provide seven-day cover because it is not commissioned to operate seven days.

    Verbatim wording from the response

    “7 day provision The service is not commissioned to run over 7 days and this is in line with other Greater Manchester NHS Trusts. The target times for reviewing patients are in line with priority categories. However, there is weekend provision currently in place in the form of out of hours guidance, available for all staff, which includes feeding regimes for patients on enteral feeding or parenteral feeding: this supports appropriate nutrition being available over weekends ensuring no delays. A copy is attached in Appendix B and C. The subsequent”

    Source location

    2021-0208-Response-from-Stepping-Hill-Hospital_Published
    Page 1 · response
    Published 28 June 2021

    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

    Existing out-of-hours guidance is considered sufficient to ensure appropriate nutrition and prevent weekend delays without routine dietetic review.

    Verbatim wording from the response

    “7 day provision The service is not commissioned to run over 7 days and this is in line with other Greater Manchester NHS Trusts. The target times for reviewing patients are in line with priority categories. However, there is weekend provision currently in place in the form of out of hours guidance, available for all staff, which includes feeding regimes for patients on enteral feeding or parenteral feeding: this supports appropriate nutrition being available over weekends ensuring no delays. A copy is attached in Appendix B and C. The subsequent”

    Source location

    2021-0208-Response-from-Stepping-Hill-Hospital_Published
    Page 1 · response
    Published 28 June 2021

    Open published response
  3. Carmarthenshire and Pembrokeshire

    AI-generated summary

    Gerwyn James Thomas · 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

    Gerwyn James Thomas was admitted to hospital after a domestic fall that caused a fractured femur and required surgery. He later developed an infection and died after being readmitted to hospital three times; the inquest recorded sepsis, multi-organ failure and infected hip surgery as the medical cause of death. Concerns included delays in responding to acute dietetic referrals, insufficient staffing, and inadequate training in nutritional assessment.

    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

    Insufficient staffing of the acute dietetic service for timely referral response

    Wider context from the report

    “1. The acute dietetic service lacks sufficient staff to respond to referrals in a timely way. ”

    Source location

    Gerwyn James Thomas · 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

    Recruit substantive staff to fill acute dietetic vacancies while continuing efforts to maintain service capacity.

    Verbatim wording from the response

    “• Pro-actively working to recruit to pending and existing acute dietetic vacancies to ensure the substantive service capacity is maintained. It has not been possible to recruit to vacancies in the acute team in recent months due to very low numbers of suitable applicants, therefore locum dietetic resource is being used while efforts to recruit substantive staff continue.”

    Source location

    2018-0342-Response-by-University-Health-Board
    Page 2 · response
    Published 18 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

    Use locum dietetic staff to support acute service capacity while substantive recruitment continues.

    Verbatim wording from the response

    “• Pro-actively working to recruit to pending and existing acute dietetic vacancies to ensure the substantive service capacity is maintained. It has not been possible to recruit to vacancies in the acute team in recent months due to very low numbers of suitable applicants, therefore locum dietetic resource is being used while efforts to recruit substantive staff continue.”

    Source location

    2018-0342-Response-by-University-Health-Board
    Page 2 · response
    Published 18 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

    Prioritise high-risk patients for rapid dietetic referral and initiate an enhanced ward-based nutritional care pathway during staffing shortages.

    Verbatim wording from the response

    “• During November and December it has not been possible to secure adequate locum support to cover existing acute service vacancies; this has necessitated contingency arrangements to ensure patients at the greatest risk are rapidly flagged to dietetics for prioritisation and an enhanced ward based nutritional care pathway has been initiated to reduce the risk of not having timely dietetic access.”

    Source location

    2018-0342-Response-by-University-Health-Board
    Page 2 · response
    Published 18 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

    Propose increased acute dietetic establishment through additional registered dietitians and unregistered dietetic support workers.

    Verbatim wording from the response

    “• To address the staffing shortfall sustainably, dietetics have proposed an increase in acute dietetic staffing in the service submission to the Health Board intermediate plan, with an incremental increase in registered dieticians and unregistered dietetic support workers.”

    Source location

    2018-0342-Response-by-University-Health-Board
    Page 2 · response
    Published 18 March 2019

    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

    Low numbers of suitable applicants have prevented recruitment and adequate locum cover for acute dietetic vacancies, limiting staffing capacity.

    Verbatim wording from the response

    “• Pro-actively working to recruit to pending and existing acute dietetic vacancies to ensure the substantive service capacity is maintained. It has not been possible to recruit to vacancies in the acute team in recent months due to very low numbers of suitable applicants, therefore locum dietetic resource is being used while efforts to recruit substantive staff continue.”

    Source location

    2018-0342-Response-by-University-Health-Board
    Page 2 · response
    Published 18 March 2019

    Open published response
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Data last updated 7 September 2026