27 Nov 2025 June Violet FINDLAY · Prevention of Future Deaths report Berkshire
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Concerns raised 4
Failure to correctly utilise care planning tools for malnutrition risks View source Failure to follow dietician advice and care plans View source Failure to properly recognise patients’ risk of malnutrition View source
Failure to monitor and record malnutrition-risk interventions View source See 1 more concern
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. 8
Action
Implement a weight-loss flag that triggers a multidisciplinary swarm huddle and individualised care planning, with compliance monitoring.
Stated by Frimley Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 December 2025. View source
Action
Deliver refresher training on nutritional risk assessment and Epic care planning through the Harm Free Care programme, with compliance monitoring.
Stated by Frimley Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 December 2025. View source
Action
Escalate patients with significant weight loss to the Ward Matron for a documented multidisciplinary swarm review including dietitians.
Stated by Frimley Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 December 2025. View source
Action
Develop a standard operating procedure for identifying, managing and escalating significant weight loss.
Stated by Frimley Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 December 2025. View source
Action
Require Divisional Directors of Nursing to provide assurance that patients’ nutrition and hydration needs are assessed, met and accurately recorded.
Stated by Frimley Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 December 2025. View source
Action
Develop and deliver updated nutrition and hydration training covering documentation, mealtimes, trays, diets and supplements, with area-level compliance monitoring.
Stated by Frimley Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 December 2025. View source
Action
Amend Epic care flowsheets to capture food and fluid intake in greater detail and disseminate supporting safety communications.
Stated by Frimley Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 December 2025. View source
Action
Run the Harm Free Care audit programme to monitor food-chart completion, nutritional care and significant-weight-loss escalation.
Stated by Frimley Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 December 2025. View source See 5 more actions
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AI-generated summary
June Violet FINDLAY · 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
June Violet Findlay fell at home on 23 October 2024, fracturing her hip and wrist, and later died at Thames Hospice on 11 December 2024 after her health deteriorated. Concerns included substantial weight loss and sub-optimal management, monitoring, recording, and auditing of the risk of malnutrition during her 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 correctly utilise care planning tools for malnutrition risks
Wider context from the report “During the course of Mrs Findlay’s 9-10 days at Frimley Park Hospital she lost at least 5.3kg from an already low weight. She had been assessed as being at high risk of malnutrition shortly after her admission. The care planning records were inconsistent about the interventions required and the level of risk. The record keeping of the actual interventions used on a daily basis to address this risk were absent or largely incomplete and I found that the ward staff did not properly follow the dietician’s advice or the care plans.
I am concerned that ward staff are not:
1. Properly recognising the risk of malnutrition to patients, even after completing the MUST2 assessments;
2. Correctly utilising care planning tools to address the risks of malnutrition ;
3. Properly monitoring and recording the interventions undertaken to address the risk. This places patients at risk due to unclear information and also means that the hospital cannot learn from mistakes or pick up near misses.
No evidence was forthcoming from the Trust at inquest that these shortcomings at Frimley Park Hospital had been acted upon despite the court hearing that 100% of the ward staff had received MUST training and records were audited on a monthly basis. This gives rise to a further concern:
4. The auditing of records does not seem to have identified the repeated failures to record required information.
” Source location June Violet FINDLAY · Prevention of Future Deaths report
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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 follow dietician advice and care plans
Wider context from the report “During the course of Mrs Findlay’s 9-10 days at Frimley Park Hospital she lost at least 5.3kg from an already low weight. She had been assessed as being at high risk of malnutrition shortly after her admission. The care planning records were inconsistent about the interventions required and the level of risk. The record keeping of the actual interventions used on a daily basis to address this risk were absent or largely incomplete and I found that the ward staff did not properly follow the dietician’s advice or the care plans.
I am concerned that ward staff are not:
1. Properly recognising the risk of malnutrition to patients, even after completing the MUST2 assessments;
2. Correctly utilising care planning tools to address the risks of malnutrition;
3. Properly monitoring and recording the interventions undertaken to address the risk. This places patients at risk due to unclear information and also means that the hospital cannot learn from mistakes or pick up near misses.
No evidence was forthcoming from the Trust at inquest that these shortcomings at Frimley Park Hospital had been acted upon despite the court hearing that 100% of the ward staff had received MUST training and records were audited on a monthly basis. This gives rise to a further concern:
4. The auditing of records does not seem to have identified the repeated failures to record required information.
” Source location June Violet FINDLAY · 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 properly recognise patients’ risk of malnutrition
Wider context from the report “During the course of Mrs Findlay’s 9-10 days at Frimley Park Hospital she lost at least 5.3kg from an already low weight. She had been assessed as being at high risk of malnutrition shortly after her admission. The care planning records were inconsistent about the interventions required and the level of risk. The record keeping of the actual interventions used on a daily basis to address this risk were absent or largely incomplete and I found that the ward staff did not properly follow the dietician’s advice or the care plans.
I am concerned that ward staff are not:
1. Properly recognising the risk of malnutrition to patients, even after completing the MUST2 assessments ;
2. Correctly utilising care planning tools to address the risks of malnutrition;
3. Properly monitoring and recording the interventions undertaken to address the risk. This places patients at risk due to unclear information and also means that the hospital cannot learn from mistakes or pick up near misses.
No evidence was forthcoming from the Trust at inquest that these shortcomings at Frimley Park Hospital had been acted upon despite the court hearing that 100% of the ward staff had received MUST training and records were audited on a monthly basis. This gives rise to a further concern:
4. The auditing of records does not seem to have identified the repeated failures to record required information.
” Source location June Violet FINDLAY · 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 monitor and record malnutrition-risk interventions
Wider context from the report “During the course of Mrs Findlay’s 9-10 days at Frimley Park Hospital she lost at least 5.3kg from an already low weight. She had been assessed as being at high risk of malnutrition shortly after her admission. The care planning records were inconsistent about the interventions required and the level of risk. The record keeping of the actual interventions used on a daily basis to address this risk were absent or largely incomplete and I found that the ward staff did not properly follow the dietician’s advice or the care plans.
I am concerned that ward staff are not:
1. Properly recognising the risk of malnutrition to patients, even after completing the MUST2 assessments;
2. Correctly utilising care planning tools to address the risks of malnutrition;
3. Properly monitoring and recording the interventions undertaken to address the risk. This places patients at risk due to unclear information and also means that the hospital cannot learn from mistakes or pick up near misses.
No evidence was forthcoming from the Trust at inquest that these shortcomings at Frimley Park Hospital had been acted upon despite the court hearing that 100% of the ward staff had received MUST training and records were audited on a monthly basis. This gives rise to a further concern:
4. The auditing of records does not seem to have identified the repeated failures to record required information.
” Source location June Violet FINDLAY · 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 Implement a weight-loss flag that triggers a multidisciplinary swarm huddle and individualised care planning, with compliance monitoring.
Verbatim wording from the response “1. Implement a new system to flag patients with a concerning weight loss which triggers a swarm huddle. A swarm huddle is designed to start as soon as possible after a patient safety incident occurs so in this case significant weight loss is identified. The purpose of the swarm-based huddle is to identify learning from patient safety incidents; this is in line with the National Patient Safety Framework (PSIRF). Immediately after an incident this identified the multidisciplinary staff ‘swarm’ to the ward to quickly analyse what happened and how it happened and decide what needs to be done to reduce risk. Swarms enable insights and reflections to be quickly sought and generate prompt learning. It will be expected that the swarm is attended by the Ward Matron and a member of the Patient Safety Team.” Source location Response from Frimley Health NHS Foundation Trust
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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 Deliver refresher training on nutritional risk assessment and Epic care planning through the Harm Free Care programme, with compliance monitoring.
Verbatim wording from the response “Harm Free Care - A trust campaign was launched in July 2025 to support a focus on 4 key areas relating to improving patient safety. This included improving nutritional care for patients to ensure they are assessed for nutritional status and risk of malnutrition using the malnutrition universal screening tool (MUST). If they are malnourished or at risk, interventions will be implemented to ensure that their status is improved as much as possible.” Source location Response from Frimley Health 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 Escalate patients with significant weight loss to the Ward Matron for a documented multidisciplinary swarm review including dietitians.
Verbatim wording from the response “3. All patients who are identified with significant weight loss in line with the SOP will be escalated to the Ward Matron who will ensure that a full swarm review including dieticians is undertaken and appropriate actions are taken and clearly documented.” Source location Response from Frimley Health 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 Develop a standard operating procedure for identifying, managing and escalating significant weight loss.
Verbatim wording from the response “2. Develop a Standard Operating Procedure (SOP) for the identification, management and escalation of weight loss.” Source location Response from Frimley Health 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 Require Divisional Directors of Nursing to provide assurance that patients’ nutrition and hydration needs are assessed, met and accurately recorded.
Verbatim wording from the response “4. Divisional Directors of Nursing (DDONS) within the new Divisional Structure will be required to provide assurance to the Chief of Nursing and Midwifery that the nutrition and hydration needs of patients cared for in their division are being assessed and consistently met and accurately recorded.” Source location Response from Frimley Health 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 Develop and deliver updated nutrition and hydration training covering documentation, mealtimes, trays, diets and supplements, with area-level compliance monitoring.
Verbatim wording from the response “3. A thorough review/map of all the education programmes/study days that are provided for both registered nurses and healthcare support workers is underway. The aim is to ensure that the training we are providing all staff is fit for purpose. The new education programme will address the following key concerns: documentation to ensure accurate recording of food consumption, protected mealtimes, tray colours and ensuring the patient receives the correct diet for example soft, and when supplements should be given. All staff will be given the updated training and compliance for each clinical area will be monitored by the NHSSG.” Source location Response from Frimley Health 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 Amend Epic care flowsheets to capture food and fluid intake in greater detail and disseminate supporting safety communications.
Verbatim wording from the response “5. Review of how Food & Fluid intake can be documented on Epic (Trust Electronic Patient Record) - the daily care flowsheets have been amended to allow for nutritional intake to be documented in more detail. Safety message and electronic patient record (EPR) bulletins have gone out to clinical staff.” Source location Response from Frimley Health 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 Run the Harm Free Care audit programme to monitor food-chart completion, nutritional care and significant-weight-loss escalation.
Verbatim wording from the response “Audit – There will be an altered focus on the audit to provide assurance that patients are adequately fed according to their need and that any significant weight loss is appropriately escalated to the Ward Matron to ensure that high risk patients are highlighted and appropriate action is taken and documented in line with the new weight loss SOP.” Source location Response from Frimley Health NHS Foundation Trust
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23 Jun 2025 REDACTED Deceased · Prevention of Future Deaths report Northumberland
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Concerns raised 1
Lack of in-person dietetic assessment recording weight and clinical observations View source
This report raised 9 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.
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AI-generated summary
REDACTED Deceased · 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
The deceased was a 17-year-old girl with autism, anxiety, significant weight loss and extreme malnutrition who died in hospital on 5 May 2024 after cardiac output was lost following vomiting during preparation for insertion of a central venous line. The principal concerns included inadequate monitoring of her weight, lack of face-to-face assessments, failure to refer or escalate care appropriately, discharge from CAMHS without direct assessment, poor communication and unclear oversight of outpatient care.
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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 in-person dietetic assessment recording weight and clinical observations
Wider context from the report “4.There was no in person assessment by dietetics or escalation of care
The deceased was assessed via telephone on all occasions. I am concerned that whilst telephone assessments expedited contact there was no in person face to face assessment to record weight or to take and record clinical observations .
At assessment on 2 January 2024, the deceased was not aware of her current weight. A weight history from the 20 November 2023 and a 2022 weight were noted. Her BMI was calculated as 17.
On 5 March 2024 the deceased was reviewed by a specialist dietitian again by telephone. The deceased self-reported her weight to be 33kg with a calculated BMI of 13.4.
The Medical Emergencies in Eating Disorders (MEED) guidelines are used to identify at the earliest stage possible the appropriate care and treatment to be provided. It identifies BMI calculators in the green, amber and red.
Red or high risk would be a BMI less than 13.
The next specialist dietitian review took place on 26 April 2024, 2 weeks later than planned again by telephone. The self-reported weight was 31.8kg with a calculated BMI of 12.9
I am concerned that there was no escalation of care or onward referral, and I am concerned about staff’s understanding of the Medical Emergencies in Eating Disorders (MEED) guidelines.
” Source location REDACTED Deceased · 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 Reinforce face-to-face contact requirements for patients with weight loss or malnutrition through team reminders and monthly meetings.
Verbatim wording from the response “• Enhanced Face-to-Face Contact: The GP surgery already runs a primarily face-to-face appointment system, but we have reminded the team of the importance of this means of access, particularly where weight loss or malnutrition is a concern, to ensure accurate physical assessments. We will continue to reiterate the importance of face to face contacts at our monthly meetings and when any changes to appointment ledgers are considered.” Source location 2025-0314 - Response from 49 Marine Avenue Surgery
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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 Routinely offer face-to-face Dietetics appointments as first contact for patients referred for nutritional support or weight loss, with in-person follow-up after necessary telephone assessment.
Verbatim wording from the response “9. From August 2025, face to face appointments are now routinely offered by the Dietetics service as first contact for any patient referred for nutritional support and weight loss (irrespective of the cause). If telephone contact is required for timeliness, then an in-person review appointment will then be offered after the initial telephone assessment.” Source location 2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
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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 Cascade safety messages on accurate height and weight measurement, assessment frequency and documentation through Trust communications and policy.
Verbatim wording from the response “11. Internal communications and safety messages have been cascaded to Trust staff regarding the importance of obtaining accurate height and weight measurements in July 2025, including frequency of assessment and clarity on how the measurements were obtained, documented within the approved Trust-wide Nutrition and Hydration Policy.” Source location 2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
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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 Offer home visits to higher-risk patients who cannot or will not attend an in-person Trust appointment.
Verbatim wording from the response “29. The standard referral criteria to the Dietetics service for nutrition support is patients with a BMI of less than 18.5 and/or 5-10% weight loss within 3-6 months. Higher risk patients (i.e. those referred with a BMI of less than 17.5, in line with MEED definitions for immediate risk to life) can now be offered a home visit, if it is felt that the patient won't or can't attend an in-person appointment at one of the Trust sites.” Source location 2025-0314 - Response from Northumbria 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 Offer face-to-face appointments to all higher-risk patients, using telephone contact only when needed for timely intervention and followed by in-person review.
Verbatim wording from the response “30. All higher risk patients will be offered a face-to-face appointment going forward and if a telephone contact is required to facilitate a timely intervention it will be followed by an in-person appointment to ensure accurate weight and height is recorded. Face-to-face appointments for all patients who are not triaged as ‘higher risk’ are offered where possible and would be based on individual clinical need and may require further commissioning discussions.” Source location 2025-0314 - Response from Northumbria Healthcare NHS Foundation 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 A return to face-to-face appointments as standard requires additional resources and a commissioning review, preventing immediate universal implementation.
Verbatim wording from the response “27. The Dietetics service aims to return to a pre-COVID out-patient position whereby face-to-face appointments are offered as standard for all appointments. However, this is likely to require additional resource and a commissioning review. In the meantime, face to face appointments will be prioritised to all younger persons with red flags for low BMI.” Source location 2025-0314 - Response from Northumbria Healthcare NHS Foundation 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 service cannot guarantee that every first appointment will be face-to-face because patient choice may prevent this.
Verbatim wording from the response “32. The Trust acknowledges (e.g. because of patient choice) that it is not always possible to guarantee all first appointments are face-to-face, but that, all first attendance appointments should be face-to-face where clinically appropriate, and this standard has been set at the Outpatient Steering Group.” Source location 2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
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20 May 2025 Marina Lorraine Waldron · Prevention of Future Deaths report Gwent
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Concerns raised 1
Failure to respond to low albumin indicating malnutrition View source
This report raised 3 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.
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AI-generated summary
Marina Lorraine Waldron · 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
Marina Lorraine Waldron was admitted to hospital on 17 December 2023 with gastrointestinal bleeding caused by angiodysplasia and died on 15 February 2024 despite appropriate treatment. During her admission, her nutritional needs were poorly considered or managed, including failures to respond to family concerns, monitor dietary intake, act on a low albumin level, and consider dietary advice and parenteral feeding promptly. The medical staff who gave evidence agreed that malnutrition 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 Failure to respond to low albumin indicating malnutrition
Wider context from the report “During the 8 ½ weeks of MW’s hospital admission, her nutritional needs were poorly considered or managed.
Examples of this include:
1. An ongoing failure to heed the family’s concerns that from admission to hospital, MW was not eating or drinking adequately
2. A failure to formally monitor MW’s dietary intake
3. A failure to respond to a low Albumin level which is a sign of malnutrition
4. Dietary advice and parenteral feeding were not properly considered until 29/1/2024 (6 weeks after admission)
The medical staff who gave evidence agreed that malnutrition contributed to MW’s death.
” Source location Marina Lorraine Waldron · 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 Embed improved escalation protocols for malnutrition risk within the Quality Management System.
Verbatim wording from the response “The introduction of this governance framework has already supported the implementation of key improvement actions at pace, including enhanced monitoring of fluid balance, improved escalation protocols for malnutrition risk, and strengthened documentation and compliance monitoring. These initiatives are being embedded within our Quality Management System and have enabled a more responsive and accountable approach to preventing avoidable harm.” Source location Response from Aneurin Bevan University Health Board
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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 Conduct a thematic review of delayed escalations involving nutritional concerns.
Verbatim wording from the response “Under Recommendation 3, we are strengthening escalation frameworks to support timely clinical decision-making. Key actions include:” Source location Response from Aneurin Bevan University Health Board
Open published response
Concerns raised 1
Failure to complete malnutrition universal screening tool assessments View source
This report raised 6 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.
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AI-generated summary
Raymond Albert Alfred Reid · 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
Raymond Albert Alfred Reid was admitted to hospital with a catheter-related urinary tract infection, developed pressure sores and pneumonia during a prolonged stay, and died on 1 March 2023. The report identified concerns about gaps in pressure sore prevention, monitoring, documentation, nutritional screening, repositioning, wound follow-up and photography.
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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 complete malnutrition universal screening tool assessments
Wider context from the report “(2) The pressure sores developed in hospital and the deterioration of the pressure sores was possibly caused by gaps in care and knowledge. More particularly the evidence at the inquest (and the findings of an internal concise investigation) revealed that:
a. A first skin check was not completed within 6 hours of admission in accordance with Trust policy.
b. The pressure ulcer risk assessment was not completed within 6 hours of admission and was not repeated daily in accordance with Trust policy.
c. Skin checks were not routinely documented – there were 21 intermittent days when a skin check was not recorded.
d. A malnutrition universal screening tool assessment was not completed in accordance with Trust policy.
e. There were long periods when Mr Reid was not moved – there were episodes during 15/2/23 to 21/2/23 when Mr Reid was not documented to have been moved for 5-10 hours. This is not best practice.
f. Following a Tissue Viability Team assessment there was no follow up planned – this should have been planned to monitor wound progression.
g. No photographs were taken between 8/2/23 and 21/2/23. The taking of photographs represents best practice to enable the progress and/or deterioration of a wound to be fully understood.
” Source location Raymond Albert Alfred Reid · Prevention of Future Deaths report
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14 Oct 2024 Stephen Frederick DULLING · Prevention of Future Deaths report North Yorkshire and York
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Concerns raised 1
Failure to implement and maintain food charts after malnutrition risk assessment View source
This report raised 9 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.
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AI-generated summary
Stephen Frederick DULLING · 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
Stephen Frederick Dulling, who had Parkinson’s disease, symptoms of dementia and swallowing problems, was admitted to York District Hospital and choked while eating toast, subsequently dying from aspiration pneumonia. Concerns included the response to reported risks before admission and multiple nursing-care lapses during his hospital admission, including the appropriateness of his diet, nutritional monitoring, response to choking and incident investigation.
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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 implement and maintain food charts after malnutrition risk assessment
Wider context from the report “4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings –
a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity;
b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above;
c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment ;
d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids;
e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking;
f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest.
5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others.
” Source location Stephen Frederick DULLING · 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 Consolidate eating, drinking and nutrition assessments into one Nucleus section.
Verbatim wording from the response “It is accepted that the assessment of Mr Dulling’s nutritional needs on admission was not detailed enough and that a food chart was not instigated/completed when it should have been.
The Trust’s Food, Nutrition and Hydration Policy (available if required) was updated in November 2024. There are currently several assessments, relating to eating and drinking and nutrition, that nursing staff undertake when a patient is admitted. These assessments are not all located in the same place and not as intuitive as they could be. We recognise that this is” Source location Response from York and Scarborough Teaching Hospitals NHS Foundation Trust
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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 Carry out quality-improvement work addressing poor compliance with nutritional assessment and food-chart requirements.
Verbatim wording from the response “not optimal and are in the process of bringing these assessments together into one section of Nucleus (electronic digital nursing record) and this is due to go live in January 2025. We are confident that this will significantly reduce the risk of essential information being overlooked. The Trust recognises the previous poor compliance in this area, as identified in Mr Dulling’s case, and this is a focus of current quality improvement project work. The Trust has completed a Patient Safety Incident Investigation (PSII) cluster review of Speech and Language Therapy (SLT) and swallow related incidents. This was presented to the Trust’s Serious Incident Group in December 2024 with an associated action plan.” Source location Response from York and Scarborough Teaching Hospitals NHS Foundation Trust
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10 Sep 2024 James Astley · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to correctly complete MUST documentation View source
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. 5
Action
Conduct an assessment and inspection of Downshaw Lodge to verify required changes, including staff training, accurate needs assessment, care planning, and documentation.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 11 September 2024. View source
Action
Complete an IMPACT audit of documentation, nutrition and fluid-recording practice.
Stated by Qualia Care Limited (In AdministrationStated completedThe respondent said that this action was complete when they made their response on 11 September 2024. View source
Action
Train staff in MUST, fluid and nutrition care, documentation, record-keeping and dietary-risk escalation.
Stated by Qualia Care Limited (In AdministrationStated completedThe respondent said that this action was complete when they made their response on 11 September 2024. View source
Action
Provide annual MUST refresher training for all new starters.
Stated by Qualia Care Limited (In AdministrationStated plannedThe respondent said that this action was planned when they made their response on 11 September 2024. View source
Action
Conduct daily management walkarounds and weekly regional oversight visits to verify nutritional care-plan implementation and MUST accuracy.
Stated by Qualia Care Limited (In AdministrationStated completedThe respondent said that this action was complete when they made their response on 11 September 2024. View source See 2 more actions
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James Astley · 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
James Astley had dementia, was immobile, and became increasingly frail following worsening nutrition, fluid intake, and swallowing difficulties. He was admitted to hospital with urosepsis and dehydration and died there on 22 January 2024. The concerns included incorrectly completed MUST documentation, poor-quality fluid and nutrition charts, and limited, insufficiently detailed documentation at the care home.
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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 correctly complete MUST documentation
Wider context from the report “1. The inquest heard evidence that Mr Astley was at significant risk due to poor nutrition and fluid intake. However the MUST documentation was not correctly completed and the overall quality of fluid and nutrition charts was poor. As a consequence he became increasingly frail and the risk to his overall wellbeing and physiological reserves continued.
2. Overall documentation at the home was limited and lacked detail
” Source location James Astley · 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 Conduct an assessment and inspection of Downshaw Lodge to verify required changes, including staff training, accurate needs assessment, care planning, and documentation.
Verbatim wording from the response “Subsequent to the Regulation 28 preventing future death report CQC have commenced an assessment at Downshaw Lodge to ensure the required changes have been made, especially in regard to ensuring staff have received the training and support needed to complete accurate assessment of people’s needs, take appropriate action and following care plans in line with people’s needs to ensure all care needs are met, and maintain accurate and contemporaneous needs. This assessment was commenced on 16 October 2024. Once this has been completed a report will be published on the CQC website with our findings. This can be found on the link” Source location Response from CQC
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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 Complete an IMPACT audit of documentation, nutrition and fluid-recording practice.
Verbatim wording from the response “By way of background, the Registered Manager commenced employment at the Home in early December 2023 following an induction into the service. In December 2023, the Regional Manager identified a need for improvement in the completion of documentation by staff, and an action plan was developed. Due to the concerns identified, a Quality Manager subsequently completed an internal IMPACT audit in January 2024.” Source location Response from Downshaw Lodge
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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 Train staff in MUST, fluid and nutrition care, documentation, record-keeping and dietary-risk escalation.
Verbatim wording from the response “MUST Training and Competency:” Source location Response from Downshaw Lodge
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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 annual MUST refresher training for all new starters.
Verbatim wording from the response “• MUST Training: as detailed above. Refresher training will be completed annually at the home for all new starters.” Source location Response from Downshaw Lodge
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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 Conduct daily management walkarounds and weekly regional oversight visits to verify nutritional care-plan implementation and MUST accuracy.
Verbatim wording from the response “Staff at the Home have ready access to all resident care plans and the Registered Manager also conducts daily walkarounds to ensure that care plans, including nutritional needs, are being adhered to.” Source location Response from Downshaw Lodge
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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 provider actions, multi-agency oversight and available documentation processes were considered sufficient to address identified care and recording risks.
Verbatim wording from the response “CQC first became aware of the death of Mr Astley on 30 January 2024 when a statutory notification of death was submitted by the provider. This was assessed by an inspector at the time who sought further information due to the notification indicating that a safeguarding referral had been raised against the care home. The safeguarding investigation records were reviewed and although areas of learning were noted for the provider, CQC was assured that the necessary actions were already in progress. These actions included ensuring all people living at the home had up to date and relevant care plans as well as training for staff around the use of the digital health service in order to effectively escalate health concerns.” Source location Response from CQC
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14 May 2024 Carol Ann DIVALL · Prevention of Future Deaths report East Sussex
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Concerns raised 1
Delays in providing nutritional supplementation View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Carol Ann DIVALL · 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
Carol Ann DIVALL had Alzheimer's disease and sustained a hip fracture at home on 15 September 2022, which was surgically repaired during a hospital admission. She was discharged on 24 October 2022 for end-of-life care and died at home on 29 October 2022. Concerns included severe oral thrush and malnutrition, limited mobilisation, development and deterioration of a grade 4 sacral pressure sore, and misleading or incomplete discharge documentation and investigation.
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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 providing nutritional supplementation
Wider context from the report “A. That Mrs Divall developed severe oral thrush making it very difficult for her to eat and drink and take her oral medication. She was referred to the dietitians on 2.10.22 and triaged by an Assistant the following day. She was not prescribed Fortisip until 14.10.22 by which time she was becoming malnourished. The oral thrush continued until discharge. Nystatin appeared to be prescribed once on 12.10.22 and was not prescribed on discharge nor mentioned in the discharge summary. I heard evidence on PFD matters that software which requires a clinician to check oral care is being implemented. I remain of the opinion that this forms part of basic nursing care which was overlooked in Mrs Divall's case.
” Source location Carol Ann DIVALL · 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 Conduct regular senior nurse-led audits of compliance with MUST treatment plans.
Verbatim wording from the response “We have developed regular senior nurse-led audits to measure the quality of compliance with the treatment plan for MUST. Plans are also in place for a Trust wide audit of the quality MUST assessments, including evidence of treatments commenced.” Source location Response from East Sussex Healthcare
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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 Undertake a Trust-wide audit of MUST assessment quality and treatment evidence.
Verbatim wording from the response “We have developed regular senior nurse-led audits to measure the quality of compliance with the treatment plan for MUST. Plans are also in place for a Trust wide audit of the quality MUST assessments, including evidence of treatments commenced.” Source location Response from East Sussex Healthcare
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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 Update Dietetic Assistant competencies and provide training and support on accurate referral coding.
Verbatim wording from the response “Turning to the prescription of Fortisip, this is typically undertaken following a registered dietitian’s assessment. We accept that doctors could have prescribed this prior to review by a dietitian in this case. On this occasion due to a coding error at the point of triage, the urgency of our response is not as it should have been. Dietetic Assistant (DA) competencies have now been updated and additional training and support are given to DAs regarding the importance of coding correctly at this point in the pathway, to minimise the potential for recurrence of this error.” Source location Response from East Sussex Healthcare
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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 Remind ward staff to offer suitable nourishing drinks before dietitian review and promote high-calorie, high-protein ward options.
Verbatim wording from the response “Following the completion of the MUST or mouthcare assessment on admission, the dietitians will have base line information to work from to enable a full assessment of the patient. Any concerns are highlighted to dietitians via the referral process and from communication with the MDT, patient and family. As part of the learning implemented following Mrs Divall’s experience, all ward staff have received escalated communications to remind them that they can offer nourishing drinks such as Complan shakes and thickened yoghurts prior to dietitian referral or review, as long as there are no concerns about swallowing difficulties/dysphagia. The Dietetic team additionally promote the availability of high calorie, high protein options on the wards to staff and patients.” Source location Response from East Sussex Healthcare
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25 Nov 2022 Mrs Joan Robinson · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Failure to mandate Malnutrition Universal Screening Tool training for nurses and healthcare assistants View source Failure to achieve completion of Malnutrition Universal Screening Tool training View source
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.
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Mrs Joan Robinson · 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 Joan Robinson was admitted to hospital after sustaining multiple cervical spinal fractures in a fall at home. During her admission she developed confusion, difficulty swallowing, poor oral intake, atrial fibrillation, congestive cardiac failure and acute kidney injury, and palliative care was instituted. Concerns related to incomplete and non-mandatory training in the Malnutrition Universal Screening Tool and insufficient support, holding or attendance for the Trust’s Nutrition and Hydration Committee.
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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 mandate Malnutrition Universal Screening Tool training for nurses and healthcare assistants
Wider context from the report “2. Connected with the above, it is a matter of concern that whilst the Trust describes this training as ‘essential’ it is not deemed mandatory for completion by certain staff groups such as nurses and healthcare assistants ;
” Source location Mrs Joan Robinson · Prevention of Future Deaths report
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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 achieve completion of Malnutrition Universal Screening Tool training
Wider context from the report “1. The court heard evidence that, despite training on the Malnutrition Universal Screening Tool being regarded by the Trust as ‘essential’, the completion rate of training within the organisation is currently just 58.74% ;
” Source location Mrs Joan Robinson · Prevention of Future Deaths report
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23 Dec 2021 Margaret Rose Toye · Prevention of Future Deaths report East London
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Concerns raised 2
Inaccurate recording of MUST malnutrition risk scores View source Failure to assess all patients for malnutrition risk using the MUST score system View source
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.
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Margaret Rose Toye · 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
Margaret Rose Toye, aged 81, sustained an unwitnessed fall on 10 April 2021, suffered a left neck of femur fracture, underwent surgery on 12 April, and died following a cardiac arrest on 20 April 2021. The principal concern was that she was not assessed for malnutrition using the MUST score system; her records incorrectly recorded a score of 0, and it was considered likely that she would have scored 4, which would have prompted mitigations to maximise her nutritional intake. Contemporary ward audits indicated that one in ten patients were not assessed for malnutrition risk.
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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 Inaccurate recording of MUST malnutrition risk scores
Wider context from the report “1. Following admission, Mrs Toye was not assessed for risks of malnutrition by use of the MUST score system. Such an assessment was required for all patients. Erroneously, her notes recorded that she scored 0 on the MUST scale which meant that no other staff members began an assessment throughout her admission . It is likely that during admission Mrs Toye would have scored 4 on a MUST assessment, as such a number of mitigations would have been introduced to maximise her nutritional intake.
2. Contemporary audits of compliance of Must scoring on the ward in question demonstrate that one in ten patients are not being assessed for risks of malnutrition.
” Source location Margaret Rose Toye · Prevention of Future Deaths report
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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 assess all patients for malnutrition risk using the MUST score system
Wider context from the report “1. Following admission, Mrs Toye was not assessed for risks of malnutrition by use of the MUST score system. Such an assessment was required for all patients. Erroneously, her notes recorded that she scored 0 on the MUST scale which meant that no other staff members began an assessment throughout her admission. It is likely that during admission Mrs Toye would have scored 4 on a MUST assessment, as such a number of mitigations would have been introduced to maximise her nutritional intake.
2. Contemporary audits of compliance of Must scoring on the ward in question demonstrate that one in ten patients are not being assessed for risks of malnutrition .
” Source location Margaret Rose Toye · Prevention of Future Deaths report
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3 Dec 2021 TERENCE TALBOT · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Lack of regular dietitian input for malnutrition View source
This report raised 6 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.
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TERENCE TALBOT · 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
Terence Talbot died at Maidstone & Tunbridge Wells NHS Trust on 9 April 2020 from multiorgan failure due to empyema and pneumonia associated with DRESS Syndrome, following a severe reaction to prescribed medication for bipolar affective disorder. The concerns included repeated discharge and readmission, lack of formal mental-capacity assessments, insufficient dermatology review and emollient application, inadequate food and fluid leading to malnutrition, and issues concerning a requirement to attend in person to claim benefits while severely ill.
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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 regular dietitian input for malnutrition
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” Source location TERENCE TALBOT · 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 Complete and weekly repeat MUST nutrition screening for all patients to identify deterioration and dietetic intervention needs.
Verbatim wording from the response “▪ All patients continue to have a Malnutrition Universal Screening Tool (MUST) score completed on admission and weekly thereafter to detect any deterioration and ensure dietetic intervention;” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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Includes failures of controls specifically dedicated to managing malnutrition risk, including risk recognition, MUST assessment or scoring, care planning, nutritional monitoring and recording, dietetic input, and timely nutritional intervention.
