First reported 24 Jan 2014•Latest report 22 May 2026
Definition
What this concern includes
Includes failures in the dedicated nil-by-mouth process, including identifying and communicating the restriction, preventing access to prohibited food or fluids, informing visitors and carers, documenting interim instructions, and managing essential medication for patients who are nil by mouth.
Not included
Excludes general nutrition, hydration, dysphagia or mealtime failures where nil-by-mouth status is not the material unsafe condition.
Excludes failures in speech and language therapy assessment or referral after the nil-by-mouth restriction has been reliably managed, unless the nil-by-mouth process itself is deficient.
Excludes generic communication, training, documentation or staffing deficiencies unless they directly impair management of a nil-by-mouth restriction.
Excludes clinically indicated fluid restriction or medication-management concerns that are not connected to nil-by-mouth status.
Reports
7
Distinct published reports
Individual concerns
9
A report can raise multiple concerns
Date range
2014–2026
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.
Barts Health NHS Trust1
Betsi Cadwaladr University LHB1
Medway NHS Foundation Trust1
Somerset NHS Foundation Trust1
Stockton Care Limited1
University Hospitals Birmingham NHS Foundation Trust1
University Hospitals Plymouth NHS Trust1
Welsh Ambulance Services NHS Trust1
NHS trust6
Local health board1
Private limited company1
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.
Somerset
Concerns raised3
Failure to clearly document and communicate a patient’s nil by mouth status reported by family on the ward
Failure of ward staff to question a patient’s nil by mouth status when receiving a patient with dysphagia and suspected aspiration pneumonia
Failure to effectively communicate patients’ nil by mouth status from the emergency department during transfer to a ward
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Strengthen documentation, escalation, clinical review, and closed-loop communication of family-raised risks such as nil-by-mouth status.
Stated by NHS Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 August 2026.
Action
Review and standardise bedside safety information, alerts, safety huddles, briefings, and handovers to improve visibility of nil-by-mouth status.
Stated by NHS Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 August 2026.
Action
Deliver ward-based dysphagia and aspiration-risk education and promote IDDSI e-learning for clinical staff.
Stated by NHS Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 August 2026.
Action
Develop a Trust-wide SBAR handover template with mandatory dietary-status fields identifying nil-by-mouth status as a critical safety parameter.
Stated by NHS Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 August 2026.
Action
Embed a transfer safety pause requiring transferring and receiving staff to confirm key risks, including nil-by-mouth status, before handover completion.
Stated by NHS Somerset NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 August 2026.
Action
Review patient-transfer standard operating procedures for appropriate staffing, equipment, and communication processes.
Stated by NHS Somerset NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 August 2026.
Action
Conduct After Action Reviews of communication and handover incidents under Patient Safety Incident Response Framework principles.
Stated by NHS Somerset NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 August 2026.
Kent and Medway
Concerns raised1
Failure to prevent water access for patients who are nil by mouth
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Conduct recurring Trust-wide audits of nil-by-mouth care and escalate findings through safety and quality governance.
Stated by Medway NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 March 2026.
Action
Provide targeted face-to-face nil-by-mouth, supervised-water and aspiration-risk training, reinforced through care study days, handovers and safety huddles.
Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 March 2026.
Action
Standardise bedside signage, tracking-board flags, water restrictions and documentation prompts for nil-by-mouth patients.
Stated by Medway NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 March 2026.
Action
Introduce a structured nil-by-mouth checklist for non-procedural patients.
Stated by Medway NHS Foundation TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 10 March 2026.
Action
Explore automated electronic patient-record alerts for conflicting nil-by-mouth documentation and recorded water provision.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 10 March 2026.
Action
Reinforce patient safety outcomes, rather than task completion, as the measure of success.
Stated by Medway NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 March 2026.
Worcestershire
Concerns raised1
Failure of doctors to document Nil by Mouth instructions pending SALT assessment
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Teesside and Hartlepool
Concerns raised1
Failure to effectively communicate nil-by-mouth and PEG-feeding concerns to care staff
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Communicate the coroner’s concerns and effective communication requirements to all staff.
Stated by Stockton Care LimitedStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Schedule further staff meetings for employees who did not attend the 22 March 2024 meeting.
Stated by Stockton Care LimitedStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Implement an upgraded cloud-based electronic documentation system displaying residents’ risks, alerts and special instructions.
Stated by Stockton Care LimitedStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Maintain robust day and night handovers covering resident risks, complaints and concerns, with management oversight and audit monitoring.
Stated by Stockton Care LimitedStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Ensure detailed risk assessments and care plans for residents receiving modified diets or fluids.
Stated by Stockton Care LimitedStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2024.
North Wales (East and Central)
Concerns raised1
Failure to communicate nil-by-mouth status to visitors
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Plymouth, Torbay and South Devon
Concerns raised1
Inadequate staff training and awareness on Nil by Mouth management for patients requiring regular medication
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
Concerns raised1
Failure to prevent inadvertent alteration of ‘nil by mouth’ signage
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Stop using amendable double-sided nil-by-mouth signs and issue signs carrying the same instruction on both sides.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 24 January 2014.
Pin
Get email alerts
Request correction
Includes failures in the dedicated nil-by-mouth process, including identifying and communicating the restriction, preventing access to prohibited food or fluids, informing visitors and carers, documenting interim instructions, and managing essential medication for patients who are nil by mouth.
