Recurring concern

Unreliable communication of patients' nutritional requirements

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First reported 24 Jan 2014•Latest report 22 May 2026

Definition

What this concern includes

Includes failures to communicate, transfer, acknowledge or maintain patient-specific nutritional requirements and restrictions, including nil-by-mouth status, PEG-feeding information and comparable nutrition-related safety instructions, across hospital, care-home and other care settings.

Not included

  • Excludes general communication, handover or record-keeping failures where no patient-specific nutritional requirement or restriction is involved.
  • Excludes failures to assess nutritional need or provide food, fluids, supplements or feeding after the relevant requirements were reliably communicated.
  • Excludes food-hygiene, food-provider, dysphagia and choking controls unless the asserted deficiency is specifically the communication of nutritional requirements.
  • Excludes failures involving clinical decisions about nutrition where the information was communicated reliably and the problem was the decision itself.
Reports
12

Distinct published reports

Individual concerns
13

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
27

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.

Barts Health NHS Trust1
Betsi Cadwaladr University LHB1
Cwm Taf Morgannwg University Local Health Board1
Gloucestershire Hospitals NHS Foundation Trust1
Highgrove Rest Home1
New Park Residential Home1
Northampton General Hospital1
Royal Devon University Healthcare NHS Foundation Trust1
Sheffield Teaching Hospitals NHS Foundation Trust1
Somerset NHS Foundation Trust1
Stockton Care Limited1
Stoke-on-Trent City Council1
the Royal Orthopaedic Hospital NHS Foundation Trust1
Welsh Ambulance Services NHS 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. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Janine Eugenie Pierrette KAISER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of staff to appreciate the importance of prescribed nutritional supplements

    Wider context from the report

    “7. The deceased had lost a considerable amount of weight but there was no referral to a dietician (although the GP had been consulted regarding her weight loss and had prescribed supplements) The importance of the supplements was not fully appreciated by all of the staff. The deceased’s weight was maintained during a hospital stay but deteriorated on her return to New Park Nursing Home ”

    Source location

    Janine Eugenie Pierrette KAISER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Issues arising after the hospital return were not notified to the City Council, so they were not investigated by it.

    Verbatim wording from the response

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

    Source location

    2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
    Page 4 · response
    Published 14 July 2015

    Open published response

  2. Inner North London

    AI-generated summary

    Bertha CRAY · 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

    Bertha CRAY’s oesophagus was perforated during an upper-gastrointestinal endoscopy, and she later died from bronchopneumonia resulting from the perforation and surgical treatment. The report raised concerns about the possible inadvertent alteration or replacement of ‘nil by mouth’ signage, uncertainty about how this occurred, and the lack of demonstrated action following the incident investigation.

    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 prevent inadvertent alteration of ‘nil by mouth’ signage

    Wider context from the report

    “(1) On the account provided by the nursing staff, it is possible that inadvertent alteration of ‘nil by mouth’ signage could occur in the future, due to the apparent ease with which a double-sided sign can be turned and lack of action taken as a consequence of this clinical incident. ”

    Source location

    Bertha CRAY · 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

    Stop using amendable double-sided nil-by-mouth signs and issue signs carrying the same instruction on both sides.

    Verbatim wording from the response

    “During the investigation, qualified nursing staff confirmed that the use of double-sided ‘nil-by-mouth’/‘sips of water’ signs at the bedside was not the usual practice in the Trust. In this particular case, ‘sips of water’ had been written on the other side of the sign. This practice will now stop and new signs issued with the same instruction on both sides, so there is no option to amend the signs by writing on them.”

    Source location

    2014-0037-Response-by-Barts-Health-NHS
    Page 1 · response
    Published 24 January 2014

    Open published response
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Data last updated 7 September 2026