3 Jun 2024 Isabella MCCREADIE · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Insufficient staffing in the dietetics department to address patients' dietetic needs View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
×
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
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
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
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
Open published response
18 Jun 2021 LESLEY MAWBY · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Residual staffing shortages in the dietetic team View source
Linked response
Stockport 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. 12
Stockport NHS Foundation Trust
Conduct twice-daily senior-dietitian triage and prioritise referrals using referral criteria and clinical judgement.
View source
Stockport NHS Foundation Trust
Provide weekend out-of-hours enteral and parenteral feeding guidance to ensure patients receive appropriate nutrition pending dietetic review.
View source
Stockport NHS Foundation Trust
Use a streamlined referral spreadsheet recording assessment due dates, follow-up review dates and review reasons.
View source
Stockport NHS Foundation Trust
Allocate highest-priority new and follow-up patients to available staff under senior-dietitian oversight.
View source
Stockport NHS Foundation Trust
Review dietetic staffing risks monthly through divisional governance and the Risk Management Committee.
View source
Stockport NHS Foundation Trust
Develop and progress a business case for increased nutrition and dietetic staffing through Trust governance.
View source
Stockport NHS Foundation Trust
Recruit to additional nutrition and dietetic posts to address identified staffing needs.
View source
Stockport NHS Foundation Trust
Complete a dietitian job-planning exercise and benchmark staffing against British Dietetic Association recommendations.
View source
Stockport NHS Foundation Trust
Review the skill mix and examine non-registered staff roles and responsibilities.
View source
Stockport NHS Foundation Trust
Combine community and acute nutrition and dietetic staffing establishments to enable flexible cross-service working.
View source
Stockport NHS Foundation Trust
Combine specialist acute caseloads and prioritise them across the service.
View source
Stockport NHS Foundation Trust
Monitor caseloads regularly to ensure patients are prioritised and seen within appropriate timescales.
View source See 9 more actions
×
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Open published response
Concerns raised 1
Insufficient staffing of the acute dietetic service for timely referral response View source
This report raised 3 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. 4
Hywel Dda University LHB
Recruit substantive staff to fill acute dietetic vacancies while continuing efforts to maintain service capacity.
View source
Hywel Dda University LHB
Use locum dietetic staff to support acute service capacity while substantive recruitment continues.
View source
Hywel Dda University LHB
Prioritise high-risk patients for rapid dietetic referral and initiate an enhanced ward-based nutritional care pathway during staffing shortages.
View source
Hywel Dda University LHB
Propose increased acute dietetic establishment through additional registered dietitians and unregistered dietetic support workers.
View source See 1 more action
×
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
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
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
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
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
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
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.