Recurring concern

Failure to provide oral care to vulnerable patients

First to latest report 7 May 2015 — 6 Dec 2023

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
3

What this concern includes

Includes failures to assess, provide, record, supervise or follow up oral hygiene and denture care for vulnerable patients, including mouth care linked to meals and care for missing, poorly maintained or unusable dentures.

What is not included
  • Excludes general personal care, nutrition, hydration or dental-treatment deficiencies where oral hygiene or denture care is not the material unsafe condition.
  • Excludes isolated lost-property concerns involving dentures where no failure to provide or manage the patient's oral care is identified.
  • Excludes clinical treatment of diagnosed oral disease after appropriate oral care has been reliably provided.
  • Excludes generic staffing, training or documentation deficiencies unless they directly cause unreliable oral or denture care.

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Surrey

    AI-generated summary

    John LEE · 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

    John Lee, an 83-year-old man with dementia, died in hospital on 3 September 2022 after choking on food. The inquest recorded that he was not closely monitored or provided with effective mouth care while eating, despite recommendations to check his mouth after meals. The Court was concerned that dementia patients at the Trust may not receive mouth care after each occasion they eat, presenting a risk of future deaths.

    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 provide mouth care to dementia patients on each occasion that they eat

    Wider context from the report

    “The Court is concerned that there is a risk that dementia patients at the Trust are not receiving mouth care on each occasion that they eat and this presents a risk of future deaths. ”

    Source location

    John LEE · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review dementia patients’ admission care, dietary, swallow and mouth-care arrangements to identify safety improvements.

    Verbatim wording from the response

    “I asked ████████, Consultant Admiral Nurse for Dementia to review the care dementia patients receive specifically in relation to mouth care when eating and to include their dietary and swallow assessments from the time of their admission. The review included expertise from ████████, Mouthcare Lead; Clinical Lead for Speech and Language Therapy (SALT); and ████████, Chief Nurse Informatics Officer.”

    Source location

    Response from Surrey and Sussex Healthcare NHS Trust
    Page 2 · response
    Published 11 December 2023

    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 Cerner mouth-care documentation and recommend changes, including an initial baseline assessment.

    Verbatim wording from the response

    “3. Recommendation / Issue to be addressed: Mouth care matters on Cerner. Review mouthcare documentation on Cerner with the electronic patient record team. Action category: Corrective. Action (SMART): Mouth care. Review and recommend changes to electronic recording of mouth care matters on Cerner. This will include Initial assessment to establish base line. Action owner (job title): ████████ Deadline for action: June 2024. Expected improvement / success measures: Improved recording of mouth care matters on Cerner. Audit results / evidence: Correct Cerner documentation in place and staff aware of where to record mouth care.”

    Source location

    Response from Surrey and Sussex Healthcare NHS Trust
    Page 4 · response
    Published 11 December 2023

    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

    Introduce nurse-rounding documentation to record assistance offered, accepted or declined for food, fluids and mouth care.

    Verbatim wording from the response

    “4. Recommendation / Issue to be addressed: Mouth care matters. Staff complete mouthcare sections correctly on Cerner. Mouth care recommendation for patients who have been identified as a swallowing risk due to dysphagia. Action category: Directive. Action (SMART): Mouth care. Nurse rounding section (Assist with food/fluid/mouthcare). Record if assistance offered and accepted, declined etc. Action owner (job title): ████████ Deadline for action: Dec 2024 (dependent on Cerner being updated). Expected improvement / success measures: Improved recording of mouthcare assessment and provides evidence that mouthcare needs have been met. Audit results / evidence: Complete audit of use of Mouth care recording on Cerner of patients with dysphagia (from Cerner list of patients with Dysphagia).”

    Source location

    Response from Surrey and Sussex Healthcare NHS Trust
    Page 4 · response
    Published 11 December 2023

    Open published response

  2. Brighton and Hove

    AI-generated summary

    Jack MOLYNEUX · 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

    Jack MOLYNEUX was awaiting discharge to a nursing home after admission to a ward for elderly male patients, where he had dementia but no acute physical illness. The report describes concerns about inadequate care, including failures relating to mobility, hydration, nutrition, mouth care, personal hygiene, psychological wellbeing, stimulation and medication, and states that these omissions and failings contributed to his death. His death was unexpected after transfer to the nursing home, where his condition and engagement reportedly improved.

    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 provide mouth and denture care

    Wider context from the report

    “Mr Jack MOLYNEUX was awaiting discharge to an appropriate Nursing Home. He was on a 19 bedded ward for elderly male patients and during that time he was not suffering from any acute physical illness, but he did however have moderately advanced mixed alzheimer’s and vascular dementia and he needed to be mobilised, he needed to be appropriately hydrated and have his nutrition maintained. He needed mouth care, he had dentures but the top plate was lost. He needed personal hygiene, he needed to have his psychological wellbeing maintained and he needed stimulation and he also needed to have his medications given to him appropriately. It was clear that he did not have mental capacity, it was clear that he could not consider the consequences of his decisions not to accept care or hydration and nutrition or his medications and yet no consideration was given of placing him on a Deprivation of Liberty Safeguarding Order. He needed, but he didn’t receive full care in respect of all the matters mentioned above. Mobility He was never helped to mobilise or to maintain the good mobility which he had when he came into hospital. He was never offered to have his out door clothes and perhaps to be assisted to go down to the hospital shop to buy a newspaper which was something he used to do every day before he came into hospital. He lost 20% of his bodyweight in the one calendar month when he was in hospital and absolutely no note was taken of this and he wasn’t referred to the dieticians until he had been in hospital for almost that full calendar month. His mouth was in such an appalling state when he moved to his nursing home that the nursing home immediately raised a safeguarding alert on the grounds of neglect. His dentures were lost and his mouth was in such a poor state that the staff, on Vallance Ward, were unaware that he even had a lower plate in his mouth. His personal hygiene was such that whilst it was noted he was washed there was no evidence whatsoever that he was ever offered a bath or shower in the four weeks of his admission. There was no evidence whatsoever that any form of stimulation was provided. There was a television by his bed but no evidence that anybody ever discussed with him whether he might like to watch anything on it. With regard to his psychological wellbeing this appeared from the evidence before me to have been completely disregarded. Finally with regard to his medications he refused all his medications on an inconsistent basis but he did take his Memantine for pretty well every day of his hospital admission apart from on a couple of occasions just before he was discharged. At the Inquest I found that whilst he had been neglected during his admission, the circumstances did not reach the required standards for a conclusion of neglect contributing his death. I believe this to be one of the most disturbing cases of sub optimal care that I have come across recently and I am not at all satisfied that this Inquest will result in any effective action being taken which is why I am concerned to follow up this matter and to ensure that all those who should know about this situation are informed. Certainly I found that the above omissions and failings contributed to Mr Molyneux’s death. When he arrived at the nursing home he came on the evening of the 25th January and on the 26th the staff at Partridge House achieved an almost miraculous transformation. He was dressed, although he needed the help of two members of staff, he was on his feet and assisted to mobilise to the toilet, he was sitting out in a bucket chair with other residents and was entertained with a film, his mouth was cleaned, the GP provided mouth wash and mouth gel which was applied. His halitosis which had been so strong that it could be smelt outside his room at Partridge House was resolved, he was smiling and reasonably responsive and was eating and drinking again and also engaged with his son, waving goodbye to him when he had visited on the 26th or 27th. His death was unexpected. Partridge House staff had hoped that whilst he would not have been able to go home he could at least have a reasonable standard of life and be enabled to be content. Finally, it is of note that an urgent DOLS was put in place on the morning of the 27th January 2016. ”

    Source location

    Jack MOLYNEUX · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Brighton and Hove

    AI-generated summary

    Mrs. Evelyn KENNEDY · 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

    Mrs. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.

    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 provide required personal and oral care

    Wider context from the report

    “(1) Once again my concerns involve the Acute Medical Unit (AMU). (2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. (4) She arrived unkempt. (5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care. (6) She felt cold and said she was cold. (7) She had been incontinent of faeces and had not been cleaned for some time. (8) She had no name wrist band. (9) In spite of known allergies she had no allergy wrist band. (10) In spite of falling regularly she had no falls risk wrist band. (11) She still had an IV cannula in place; this should have been removed after 72 hours. (12) Her daily catheter care bundle had not been completed for 3 days. (13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th. (14) Care plans were not completed for 17th, 18th, 19th or 20th. (15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th. (16) The handling assessment was not completed for 16th, 18th, 19th or 20th. (17) No food chart was completed for her entire time in AMU. (18) She had pressure damage to her hips and bottom. (19) No daily oral assessment was completed for her entire time on AMU. (20) She was not weighed. (21) The malnutrition tool was not completed. (22) Her bowel movements were not recorded. (24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart. PLUS (25) No personal care over the weekend of 18th and 19th. (26) No senior review over that weekend. (27) Not written up for her Sertraline, therefore not given (28) Not written up for any food supplements until 21st October. (29) She should have been specialled, but wasn’t. Once again AMU has been found to be chaotic and not fit for purpose. ”

    Source location

    Mrs. Evelyn KENNEDY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026