22 May 2026 Jacqueline Marie Antoinette Frehe · Prevention of Future Deaths report Somerset
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Concerns raised 2
Failure to clearly document and communicate a patient’s nil by mouth status reported by family on the ward View source Failure to effectively communicate patients’ nil by mouth status from the emergency department during transfer to a ward View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
NHS Somerset 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. 6
NHS Somerset NHS Foundation Trust
Strengthen documentation, escalation, clinical review, and closed-loop communication of family-raised risks such as nil-by-mouth status.
View source
NHS Somerset NHS Foundation Trust
Review and standardise bedside safety information, alerts, safety huddles, briefings, and handovers to improve visibility of nil-by-mouth status.
View source
NHS Somerset NHS Foundation Trust
Develop a Trust-wide SBAR handover template with mandatory dietary-status fields identifying nil-by-mouth status as a critical safety parameter.
View source
NHS Somerset NHS Foundation Trust
Embed a transfer safety pause requiring transferring and receiving staff to confirm key risks, including nil-by-mouth status, before handover completion.
View source
NHS Somerset NHS Foundation Trust
Review patient-transfer standard operating procedures for appropriate staffing, equipment, and communication processes.
View source
NHS Somerset NHS Foundation Trust
Conduct After Action Reviews of communication and handover incidents under Patient Safety Incident Response Framework principles.
View source See 3 more actions
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AI-generated summary
Jacqueline Marie Antoinette Frehe · 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
Jacqueline Marie Antoinette Frehe, aged 97, was admitted to hospital with swallowing difficulties, vomiting and suspected aspiration pneumonia. Her nil by mouth status was not communicated to ward staff, and she was given food and drink, after which she vomited, deteriorated significantly and died within about two hours. The concerns related to communication and documentation of nil by mouth status and checking this status when patients with dysphagia and suspected aspiration pneumonia arrive on the ward.
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× 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 clearly document and communicate a patient’s nil by mouth status reported by family on the ward
Wider context from the report “I heard evidence from the Ward Manager. I was not satisfied that sufficient steps had been taken to ensure that:
1. patients’ nil by mouth status is effectively communicated from the emergency department on transfer of patients to a ward setting; and
2. communication of a patient’s nil by mouth status by family is clearly documented and communicated on the ward ; and
3. ward staff question a patient’s nil by mouth status on receiving a patient with a presentation of dysphagia and suspected aspiration pneumonia.
” Source location Jacqueline Marie Antoinette Frehe · Prevention of Future Deaths report
Open source report × 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 effectively communicate patients’ nil by mouth status from the emergency department during transfer to a ward
Wider context from the report “I heard evidence from the Ward Manager. I was not satisfied that sufficient steps had been taken to ensure that:
1. patients’ nil by mouth status is effectively communicated from the emergency department on transfer of patients to a ward setting ; and
2. communication of a patient’s nil by mouth status by family is clearly documented and communicated on the ward; and
3. ward staff question a patient’s nil by mouth status on receiving a patient with a presentation of dysphagia and suspected aspiration pneumonia.
” Source location Jacqueline Marie Antoinette Frehe · 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 Strengthen documentation, escalation, clinical review, and closed-loop communication of family-raised risks such as nil-by-mouth status.
Verbatim wording from the response “To address this, we are strengthening expectations for staff to clearly document, escalate, and act upon concerns raised by families. This will include:” Source location Response from Somerset NHS Foundation Trust
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 Review and standardise bedside safety information, alerts, safety huddles, briefings, and handovers to improve visibility of nil-by-mouth status.
Verbatim wording from the response “4. Visual Identification and Safety Communication” Source location Response from Somerset NHS Foundation Trust
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 Develop a Trust-wide SBAR handover template with mandatory dietary-status fields identifying nil-by-mouth status as a critical safety parameter.
Verbatim wording from the response “1. Standardisation of Emergency Department to Ward Handover” Source location Response from Somerset NHS Foundation Trust
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 Embed a transfer safety pause requiring transferring and receiving staff to confirm key risks, including nil-by-mouth status, before handover completion.
Verbatim wording from the response “In addition, we plan to embed a ‘safety pause’ within the transfer process, requiring both transferring and receiving staff to confirm key patient risks, including NBM status, before handover is completed. This will be supported by clearer accountability, including named individuals responsible for providing and receiving handover information.” Source location Response from Somerset NHS Foundation Trust
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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 Review patient-transfer standard operating procedures for appropriate staffing, equipment, and communication processes.
Verbatim wording from the response “This programme also includes a review of our standard operating procedures for patient transfers to ensure that appropriate staffing, equipment, and communication processes are consistently in place.” Source location Response from Somerset NHS Foundation Trust
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 Conduct After Action Reviews of communication and handover incidents under Patient Safety Incident Response Framework principles.
Verbatim wording from the response “The Trust has strengthened its approach to incidents involving communication/ sharing of patient information, and handover by undertaking After Action Reviews (AARs) in accordance with the principles of Patient Safety Incident Response Framework (PSIRF). This approach supports the rapid identification of learning, promotes a systems-based understanding of the factors influencing practice, and enables proportionate improvement actions to be implemented at the point of care. Learning derived from AARs is also aggregated and considered within wider Quality Improvement workstreams, ensuring that themes relating to information sharing and ward-level handover arrangements inform our longer-term organisational improvement and risk reduction strategies This work is being done in conjunction with our Patient Safety Faculty.” Source location Response from Somerset NHS Foundation Trust
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22 Dec 2025 Elaine Jean GRIFFITHS · Prevention of Future Deaths report Northamptonshire
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Concerns raised 1
Failure to establish and communicate patients’ gluten and dairy intolerance status View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Elaine Jean GRIFFITHS · 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
Elaine Jean Griffiths died at Northampton General Hospital on 7 October 2022 from COVID pneumonitis, with congestive cardiac failure and a fall resulting in a fractured neck of femur also recorded. Concerns included incomplete fluid and diet charts, uncertainty about her gluten and dairy intolerance, limited suitable food options, and family-provided food not being recorded; the report states these matters were not causative of death in this case.
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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 establish and communicate patients’ gluten and dairy intolerance status
Wider context from the report “Given the importance of accurately monitoring both fluid and food intake in this context, I have the following concerns albeit I did not find that these matters were causative of death in the present case:-
A) The Ward Sister said in her evidence that “on occasional days, the fluid and diet charts were only partially completed”.
B) There was confusion about whether or not Mrs G was gluten and dairy intolerant. A Mental Health Nurse recorded on 31.08.22 “she was eating and drinking poorly as she follows a gluten and dairy free diet and reported the ward only give her lentil casseroles”. However, the Consultant/Orthogeriatric said in his evidence “.she had very poor oral intake and family were insisting she had an allergy to gluten and lactose despite Mrs Griffiths denying this”.
C) The family say that the choice of options for those with gluten and dairy intolerance and also requiring bite sized food was very limited, which disproportionately affects the elderly.
D) The family say that the fluid and diet charts were not accurate as the family were bringing in food and this was not being recorded. As the charts were inaccurate, this would also have made it more difficult for the dietician to offer meaningful advice.
” Source location Elaine Jean GRIFFITHS · 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 allergies and intolerances consistently in Nevercentre and discuss allergy status during daily Board Rounds.
Verbatim wording from the response “Following the implementation of NC at NGH, we have streamlined processes which has led to the improved recording of this data. This will make the recognition of allergies and intolerances easier to identify and more readily available throughout a patient’s care pathway and for future admissions. To provide you with further assurance, this detail is presented and discussed during ‘Board Rounds’ and therefore also communicated more widely to colleagues involved in a patients care.” Source location Response from University Hospitals of Northamptonshire
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14 Mar 2024 Victor Valentine Costello · Prevention of Future Deaths report Teesside and Hartlepool
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Concerns raised 1
Failure to effectively communicate nil-by-mouth and PEG-feeding concerns to care staff View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Stockton Care Limited
Communicate the coroner’s concerns and effective communication requirements to all staff.
View source
Stockton Care Limited
Schedule further staff meetings for employees who did not attend the 22 March 2024 meeting.
View source
Stockton Care Limited
Implement an upgraded cloud-based electronic documentation system displaying residents’ risks, alerts and special instructions.
View source
Stockton Care Limited
Maintain robust day and night handovers covering resident risks, complaints and concerns, with management oversight and audit monitoring.
View source
Stockton Care Limited
Ensure detailed risk assessments and care plans for residents receiving modified diets or fluids.
View source See 2 more actions
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AI-generated summary
Victor Valentine Costello · 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
Victor Valentine Costello, a resident at Primrose Court Nursing Home, was taken to hospital on 17 February 2020 and died there six days later from naturally occurring disease. Concerns were raised that information about his drinking water despite being nil by mouth and PEG fed was not effectively communicated to staff.
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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 effectively communicate nil-by-mouth and PEG-feeding concerns to care staff
Wider context from the report “Mr Costello was nil by mouth and PEG fed. His family raised concerns that Mr Costello had told them he had been drinking water from the taps in his bathroom. Evidence was given at the inquest by the Nursing Home Manager that such concerns were communicated to all staff. However, further evidence given at the inquest showed that such communication was not effective (the nurse in charge and the two care assistants who were on duty on the morning Mr Costello was taken to hospital, all denied being aware of such concerns ).
” Source location Victor Valentine Costello · Prevention of Future Deaths report
Open source 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 Communicate the coroner’s concerns and effective communication requirements to all staff.
Verbatim wording from the response “Actions | Responsible people | Time Scale
We have communicated to all staff the coroner’s concern and the importance of effective communication including use of the electronic documentation system (see item below), daily handover sheets and verbal communication between shifts. | Chief Executive- ████████
Operation Director- ████████
Home Manger- ████████
All nursing and senior staff | We had an all staff meeting on 22nd March 2024.
We will schedule further meetings for those staff who did not attend.” Source location Response from Stockton Care LTD
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 Schedule further staff meetings for employees who did not attend the 22 March 2024 meeting.
Verbatim wording from the response “Actions | Responsible people | Time Scale
We have communicated to all staff the coroner’s concern and the importance of effective communication including use of the electronic documentation system (see item below), daily handover sheets and verbal communication between shifts. | Chief Executive- ████████
Operation Director- ████████
Home Manger- ████████
All nursing and senior staff | We had an all staff meeting on 22nd March 2024.
We will schedule further meetings for those staff who did not attend.” Source location Response from Stockton Care LTD
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 Implement an upgraded cloud-based electronic documentation system displaying residents’ risks, alerts and special instructions.
Verbatim wording from the response “We are implementing an upgraded cloud based electronic documentation system where staff can easily look at each residents’ risks, alerts, and special instructions. | Chief Executive- ████████
Operation Director- ████████
Home Manger- ████████
All nursing and senior staff | The full implementation of the new electronic documentation system will be on 1st June 2024.” Source location Response from Stockton Care LTD
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 robust day and night handovers covering resident risks, complaints and concerns, with management oversight and audit monitoring.
Verbatim wording from the response “We have made sure that effective and robust handovers take place between day and night staff to include explaining risks associated with | Home Manger- ████████
All nursing and senior staff, | Ongoing.” Source location Response from Stockton Care LTD
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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 Ensure detailed risk assessments and care plans for residents receiving modified diets or fluids.
Verbatim wording from the response “The management will monitor handovers as part of our regular audits. We are also making sure that for all residents who are on modified diet and fluids, their risk assessments and care plans are detailed and will be shared with next of kin to make sure all the information is correct. | ████████- Operations Director, will keep their record of our checks and any shortfalls will be addressed. | On going” Source location Response from Stockton Care LTD
Open published response
15 Sep 2023 Geoffrey Robin Brooks · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 1
Failure of discharge summaries to clearly communicate target fluid intake View source
Linked response
Royal Devon University Healthcare 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. 7
Royal Devon University Healthcare NHS Foundation Trust
Use Epic’s Hospital Course function to build discharge summaries from clinicians’ real-time inpatient documentation.
View source
Royal Devon University Healthcare NHS Foundation Trust
Use bespoke discharge-summary templates for complex patient groups to clarify pertinent information and follow-up instructions.
View source
Royal Devon University Healthcare NHS Foundation Trust
Maintain a four-day junior-doctor rota in Medicine to reduce cross-cover and improve staffing consistency for discharge documentation.
View source
Royal Devon University Healthcare NHS Foundation Trust
Review use of the After Visit Summary across inpatient and outpatient services through an established working group.
View source
Royal Devon University Healthcare NHS Foundation Trust
Produce guidance and standard operating procedures for ward teams following the After Visit Summary review.
View source
Royal Devon University Healthcare NHS Foundation Trust
Review community-hospital staffing to develop a more robust, consistent medical team with specialty-doctor and Advanced Clinical Practitioner oversight.
View source
Royal Devon University Healthcare NHS Foundation Trust
Relaunch the Trust-wide discharge-summary working group with primary-care representation to refine discharge processes and communication.
View source See 4 more actions
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AI-generated summary
Geoffrey Robin Brooks · 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
Geoffrey Robin Brooks, who had nephrogenic diabetes insipidus, was admitted to hospital in October 2020 after his health deteriorated and died on 12 November 2020 despite treatment. The discharge summary did not clearly state that his required fluid intake of 2.5 to 3 litres per day was a target, and the target was not met while he was in the nursing home; the inquest concluded that he died from complications of nephrogenic diabetes insipidus on a background of poor fluid intake.
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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 of discharge summaries to clearly communicate target fluid intake
Wider context from the report “During his evidence the consultant physician with the responsibility for the care and treatment of Mr Brooks acknowledged that the discharge summary was ambiguous and did not make it clear that the 2.5 – 3L was a target fluid intake ; he agreed that it could be interpreted that Mr Brooks should be restricted to no more than 2.5 to 3L of fluid a day . As a consequence, the nursing home staff were unaware of the needs of Mr Brooks . The target fluid intake was not met in the period that Mr Brooks was in the nursing home, which contributed to his death.
” Source location Geoffrey Robin Brooks · Prevention of Future Deaths report
Open source 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 Use Epic’s Hospital Course function to build discharge summaries from clinicians’ real-time inpatient documentation.
Verbatim wording from the response “The RDUH switched to an electronic patient record (Epic) across its Eastern services in October 2020, which was after the date of this incident. This has led to significant improvements in documentation across inpatient and outpatient encounters. Epic has several features that help improve documentation specifically around discharge:” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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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 Use bespoke discharge-summary templates for complex patient groups to clarify pertinent information and follow-up instructions.
Verbatim wording from the response “2. Bespoke templated discharge summaries
Some areas (e.g. Stroke, Acute Care of the Elderly) have specific templates for completing discharge letters which ensures pertinent information and ongoing instructions are as clear as possible. This is important for more complex patient groups who need to have specific assessments and follow-up.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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 a four-day junior-doctor rota in Medicine to reduce cross-cover and improve staffing consistency for discharge documentation.
Verbatim wording from the response “5. Enhanced ward staffing consistency
Within Medicine, our staffing model was changed recently so that junior doctors in training have switched to a 4-day working week. Previously, compensatory rest meant that juniors were often moved from their base wards to cover rota gaps; this led to a loss of consistency in medical staffing which is a risk to discharge letters writing as discussed above. The new rota pattern means the need for cross cover is greatly reduced.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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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 Review use of the After Visit Summary across inpatient and outpatient services through an established working group.
Verbatim wording from the response “3. After Visit Summary
Epic has introduced the ability to generate a patient focused document for inpatient and outpatient attendances - the After Visit Summary (AVS) which can be given to patients at the point of hospital discharge. To date, the AVS has not been widely rolled out, particularly after inpatient stays.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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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 Produce guidance and standard operating procedures for ward teams following the After Visit Summary review.
Verbatim wording from the response “A working group has been established and will shortly begin meeting to review the use of the AVS across inpatient and outpatient areas across the Trust. Once completed, the group will produce new guidance and Standard Operating Procedures (SOPs) for ward teams, meaning the AVS would be given to the patient and the discharge summary sent electronically to the GP as a matter of routine. It clearly lays out medication changes, follow-up arrangements and can be used to provide patient’s with specific instructions. In this case, clear documentation of fluid intake requirements could have been flagged in this document.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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 Review community-hospital staffing to develop a more robust, consistent medical team with specialty-doctor and Advanced Clinical Practitioner oversight.
Verbatim wording from the response “We are currently reviewing the staffing model of our community hospitals which we hope will lead to a more robust, consistent medical team with specialty doctor and Advanced Clinical Practitioner oversight. This will provide an additional safety-net around discharge and again letters will be more likely to be written and checked by individuals who have reliably been involved in a patient’s care.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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 Relaunch the Trust-wide discharge-summary working group with primary-care representation to refine discharge processes and communication.
Verbatim wording from the response “The Trust wide discharge summary working group will be shortly relaunched with a plan to have primary care representation to try and further refine discharge processes and communication with primary care. There is potential to develop more discharge summary templates for specific specialties or conditions. We are continually working on improving the completion rates of discharge summaries and ensuring they are sent in accordance with the NHS Standard Contract agreement of within 24 hours following inpatient, day case or ED attendance.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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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 The Trust considers reviewing every discharge letter by a consultant infeasible because of resource demands, unclear responsibility, delays and risks of error.
Verbatim wording from the response “Other considerations
The Trust has considered whether every discharge letter should be reviewed by a consultant. On balance, this would not seem feasible due to:” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
Open published response
Concerns raised 1
Failure to communicate nil-by-mouth status to visitors View source
This report raised 7 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
Philip Hawkins · 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
Philip Hawkins, aged 97, suffered a fall at home on 18 March 2023, was transferred by ambulance to hospital, and died on 23 March 2023. Concerns included delays in being admitted and allocated a bed, insufficient staffing, inability to provide care, gaps in nursing documentation, and failures in aspects of assessment and treatment.
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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 communicate nil-by-mouth status to visitors
Wider context from the report “Care Concerns in the ED
4. On 18.03.22 at 02:49 there was no space for a nurse to attend to Mr Hawkins’ personal care needs or assess his pressure areas.
5. On 19.03.23 at 12:18, Mr Hawkins needed ‘repeat bloods’ but this was never done nor highlighted to clinicians.
6. On 19.03.23 at 00:31 Mr Hawkins was given oxygen but there are no nursing notes to indicate why or whether this was discussed with a clinician.
7. There is no written nursing documentation in relation to Mr Hawkins’ care from 21:52 on 19.03.23.
8. Mr Hawkins was nil by mouth but this was not made known to visitors who fed him .
” Source location Philip Hawkins · Prevention of Future Deaths report
Open source report
14 Jul 2023 Mr Terence Burns · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 1
Failure to maintain care plans with accurate nutritional requirements View source
This report raised 1 other concern. 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
Mr Terence Burns · 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
Mr Terence Burns, a resident of Highgrove Rest Home, was transferred to hospital on 28 October 2022 after his physical condition deteriorated. His blended-diet requirement was not communicated to ambulance services or the hospital, and he was later found unresponsive with food residue in his throat and died. Concerns included inaccurate care-plan information about his nutritional needs and failure to check the documents handed over during transfer.
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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 care plans with accurate nutritional requirements
Wider context from the report “The written care plan that was in place at Highgrove Rest Home did not contain the information that Mr Burns required a blended diet. Having heard the oral evidence from the two carers who attended the inquest to give evidence, I accepted that Mr Burns was being fed a blended diet in advance of his attendance at hospital on 28 October 2022.
I found that the monthly reviews of the care plan, that were carried out on 4 September and 8 October 2022, did not amend the care plan to include the need for a blended diet , and accordingly the written care plan did not accurately define the nutritional needs of Mr Burns . This missing information from the care plan was a concern for me as the documentary evidence relating to the nutritional requirements of Mr Burns was not correct .
” Source location Mr Terence Burns · Prevention of Future Deaths report
Open source report
21 Dec 2021 Eva Eileen WHEELER · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1
Lack of a protocol to inform relevant staff when an emergency ambulance is awaited so that appropriate patients are kept nil by mouth View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Eva Eileen WHEELER · 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
Eva Eileen Wheeler, aged 82, was an inpatient receiving rehabilitation after a soft tissue hip injury when she developed sigmoid volvulus, leading to abdominal perforation and her death on 17 February 2020. Concerns included a communication error that meant an emergency ambulance was not called for transfer to a major hospital, the patient was given lunch rather than being kept nil by mouth, and there was no clear protocol for joint discussion between medical and surgical registrars.
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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 Lack of a protocol to inform relevant staff when an emergency ambulance is awaited so that appropriate patients are kept nil by mouth
Wider context from the report “(2) A consequence of the communication error (above) was that Mrs Wheeler was given lunch, rather than being kept nil by mouth prior to proposed surgical assessment. There should be a protocol to inform relevant staff when an emergency ambulance is awaited, so that where appropriate, the patient is kept nil by mouth ;
” Source location Eva Eileen WHEELER · Prevention of Future Deaths report
Open source 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 Revise the process for managing patients awaiting emergency ambulances, specifying nil-by-mouth instructions, documentation, and notification responsibilities.
Verbatim wording from the response “A consequence of the communication error (above) was that Mrs Wheeler was given lunch, rather than being kept nil by mouth prior to proposed surgical assessment. There should be a protocol to inform relevant staff when an emergency ambulance is awaited, so that where appropriate, the patient is kept nil by mouth.” Source location 2021-0424-Response-from-Cwm-Taf-Morgannwg-University-Health-Board_Published
Open published response
10 Feb 2020 Joan Howard · Prevention of Future Deaths report South Yorkshire (West)
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Concerns raised 1
Delays in displaying nutritional requirements at the bedside 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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AI-generated summary
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
Open source 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 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
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 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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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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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
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16 Apr 2019 Jonathan Brett Yates · Prevention of Future Deaths report Gloucestershire
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Concerns raised 1
Failure to communicate patients' nutritional status effectively to hospital staff during admission View source
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AI-generated summary
Jonathan Brett Yates · 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
Jonathan Brett Yates, aged 68, was admitted to hospital after a fall and had a PEG feeding tube. Although he was nil by mouth, an evening meal was delivered to him; he attempted to eat it, choked, suffered cardiac arrest, and died on 20 March 2018. The substantive concern was how a patient's nil-by-mouth status and nutritional needs are communicated effectively to staff during a hospital admission.
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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 communicate patients' nutritional status effectively to hospital staff during admission
Wider context from the report “How the nutritional status of a patient, in particular when a patient is nil by mouth, is communicated effectively to staff caring for a patient during an admission to hospital.
” Source location Jonathan Brett Yates · 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 Run safety huddles on selected wards to disseminate patient-safety information and review patients’ nutritional status, including NBM changes.
Verbatim wording from the response “As a practice development, and to increase the quality of handovers, the Trust has recently introduced a pilot of the ‘safety huddle’ concept on selected wards. The aim of this daily event is enable an effective dissemination of patient safety information to the whole ward team, in a structured conversation. This looks in particular at patient needs in terms of falls risks, social work requirements, communication with relatives together with identification of the sickest patients and other immediate priorities such as nutritional status.” Source location 2019-0132-Response-by-Gloucestershire-Hospitals-NHS-Trust
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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 The concern concerns a one-off failure to use signage, not a failure to assess or manage the patient’s nutritional needs.
Verbatim wording from the response “However, the concern in this case arises from the failure on one occasion to use signage to safely and effectively communicate Mr Yates’ nutritional status to the clinical team, rather than the assessment and management of his nutritional needs.” Source location 2019-0132-Response-by-Gloucestershire-Hospitals-NHS-Trust
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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 Existing nutritional-management systems are appropriate, available and in use to safely manage patients’ nutritional care.
Verbatim wording from the response “On review of the professional processes by which nutritional status is managed, the Trust is satisfied that appropriate systems are available and in use to safely manage the nutritional care of patients.” Source location 2019-0132-Response-by-Gloucestershire-Hospitals-NHS-Trust
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1 Dec 2015 Bryan Arnold CATANACH · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Failure of communication during inter-hospital transfers View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Bryan Arnold CATANACH · 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
Bryan Arnold Catanach sustained a fractured odontoid peg and cervical injury after a fall, and died in hospital on 8 February 2015 after his condition deteriorated. The report identified concerns about communication and delays in transfer and senior review, inpatient falls prevention, and the availability and use of appropriate traction equipment.
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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 of communication during inter-hospital transfers
Wider context from the report “(1) There were a number of difficulties with communication between the various clinicians and hospital Trusts. This led to a delay in the initial transfer of the patient, a delay in his subsequent review by a senior clinician and confusion on the part of nursing staff as to whether Mr Catanach was to be kept nil by mouth and/or given his prescribed medication. While it is a matter for you it may be that the Trust will want to reflect on whether there is a need to standardize its inter-hospital transfer process so that nursing as well as medical staff are fully engaged with the process.
” Source location Bryan Arnold CATANACH · 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 Refresh and reaffirm emergency patient receiving and first-line management processes, including a ring-fenced spinal emergency bed and HDU escalation route.
Verbatim wording from the response “Difficulties with communication between various clinicians and hospital Trusts.
The Trust has looked to progress improved communication routes and systems in preparedness for the receipt of an emergency/unscheduled patient. As was explained within your Court, ROH acts as a regional centre for a range of spinal emergencies. Broadly speaking two to three spinal emergencies are transferred into the ROH each week for emergency elective care. Following this court hearing, the Trust has refreshed and reaffirmed its receiving and first line management processes in preparedness for the arrival of such patients. The Trust robustly pursues the ring fencing of a single spinal emergency bed and this provides a guaranteed safe point of arrival for any inbound emergency patient.” Source location Bryan-Catanach-Response
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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 Refresh and simplify proforma-based documentation for nursing and medical multidisciplinary teams.
Verbatim wording from the response “Additional concerns over communications
Following apparent communication and messaging issues identified in this case, Mr Newton-Ede has led a piece of work to refresh and simplify proforma based documentation. Both nursing and medical members of the multi-disciplinary team have been involved in delivering this change. There is a clearly held view from clinical colleagues that these developments have already been seen to be positively impacting on improved communication flow and necessary escalation.” Source location Bryan-Catanach-Response
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.