Recurring concern

Inadequate management of malnutrition risk

First to latest report 7 May 2015 — 27 Nov 2025

Reports that mention this concern
12
Times this concern has been raised
20
Stated actions linked to this concern
35

What this concern includes

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.

What is not included
  • Excludes generic documentation, staffing, training, audit or communication deficiencies unless the report directly ties them to malnutrition-risk management.
  • Excludes unrelated care-planning or assessment failures that do not concern malnutrition risk.
  • Excludes broader failures in general patient care or nutrition where malnutrition risk is not the identified safety concern.

Reports and published responses 12 reports

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

  1. Surrey

    AI-generated summary

    Linda Doherty · 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

    Linda Doherty died in hospital on 7 August 2017 after developing Crohn’s Disease, intestinal failure, malnutrition, sepsis and acute kidney injury. The report identified failures to follow up CT scan findings, recognise and adequately address her nutritional deterioration, and concerns about inaccurate or incomplete nutrition monitoring and the process for placing her on end-of-life care.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inaccurate scoring of Malnutrition Universal Scoring Tool charts

    Wider context from the report

    “2. The Malnutrition Universal Scoring Tool (MUST) charts for Linda Doherty were inaccurately scored during the period from 3 to 23 July 2017. Consideration should be given as to whether staff are sufficiently trained in how to score MUST charts. ”

    Source location

    Linda Doherty · Prevention of Future Deaths report
    Page 4 · concerns

    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 complete required food charts

    Wider context from the report

    “3. The food charts for Linda Doherty were not completed from 23 June to 12 July 2017 and again from 18 to 23 July 2017, despite Mrs Doherty being at risk of malnutrition. Consideration should be given as to whether appropriate procedures are in place to (i) identify those patients who require food charts and (ii) to ensure that they are properly completed. ”

    Source location

    Linda Doherty · Prevention of Future Deaths report
    Page 4 · concerns

    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 identify patients who require food charts

    Wider context from the report

    “3. The food charts for Linda Doherty were not completed from 23 June to 12 July 2017 and again from 18 to 23 July 2017, despite Mrs Doherty being at risk of malnutrition. Consideration should be given as to whether appropriate procedures are in place to (i) identify those patients who require food charts and (ii) to ensure that they are properly completed. ”

    Source location

    Linda Doherty · Prevention of Future Deaths report
    Page 4 · concerns

    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

    Delay in recognising significant patient weight loss

    Wider context from the report

    “4. The MUST charts recorded that Mrs Doherty’s weight was 65kg in early June 2017 and had reduced to 57kg by 11 July 2017, yet the multi-disciplinary team caring for her did not recognize that she had lost a significant amount of weight until 1 August 2017. Consideration should be given as to whether any additional measures or training are required to prevent similar delays in the future. ”

    Source location

    Linda Doherty · 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

    Record nutrition assessments, care plans, MUST scores, BMI, weight loss, fluid intake and food intake in the Patient Bedside Safety Booklet.

    Verbatim wording from the response

    “At the time of the patient’s admission in 2017, the recording of food charts took place on loose sheets of paper. In August 2018 the ‘Patient Bedside Safety Booklet: Risk assessments and care plans’ was introduced and is now used for all in-patients. This booklet includes all the documentation for nursing assessments, for example falls management, skin integrity and cannula care.”

    Source location

    2020-0224-Response-from-East-Surrey-Hospital-Redacted.pdf
    Page 9 · response
    Published 21 December 2020

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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

    Deliver annual MaST training on MUST scoring, nutrition screening and assessment, supported by online learning and ward-based refresher training.

    Verbatim wording from the response

    “Dietitians had identified deficiencies in ward based nutrition screening and in early 2018 reviewed the knowledge and understanding of ward based staff. Following this review, a new training package was developed based on its findings, which has now become a clinical core topic of the Mandatory and Statutory training (MaST) at SASH which staff complete annually. Compliance is monitored via the on-line Electronic Staff Record (e-ESR) and reminders are sent to staff 3 months in advance of expiry.”

    Source location

    2020-0224-Response-from-East-Surrey-Hospital-Redacted.pdf
    Page 9 · response
    Published 21 December 2020

    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

    Include MUST checks in daily ward huddles and escalate nutrition concerns to the nurse in charge.

    Verbatim wording from the response

    “All the wards now have ‘daily huddles’, where the ward team come together to discuss nursing issues and MUST is part of the daily checks. Any problems or concerns are escalated to the nurse in charge.”

    Source location

    2020-0224-Response-from-East-Surrey-Hospital-Redacted.pdf
    Page 10 · response
    Published 21 December 2020

    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

    Audit the effect of MaST nutrition training on completion of MUST documentation and address any identified deficiencies with further training.

    Verbatim wording from the response

    “4. Undertake an audit to assess the impact of the MaST nutrition training on the completion of the MUST documentation.”

    Source location

    2020-0224-Response-from-East-Surrey-Hospital-Redacted.pdf
    Page 16 · response
    Published 21 December 2020

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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 twice-weekly nutritional ward rounds led by a Consultant Gastroenterologist.

    Verbatim wording from the response

    “A need for a specialist multi professional Nutrition Support team was identified for the oversight of the provision of nutrition for patients with complex artificial feeding needs. This group is a national recommendation and aims to optimise the metabolic care of the sickest patients in hospital, by performing regular nutrition ward rounds with supporting members e.g. surgeons and feeding into the proposed complex nutrition MDT meeting. The team consists of a gastroenterology consultant, nutrition nurse specialist, senior nutrition support dietitian and a pharmacist. In October 2020, the Trust appointed a Consultant Gastroenterologist with a special interest in nutrition who has reviewed the current nutrition policies, procedures and service at SASH.”

    Source location

    2020-0224-Response-from-East-Surrey-Hospital-Redacted.pdf
    Page 10 · response
    Published 21 December 2020

    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

    Implement a formal complex nutrition MDT meeting with active surgeon membership.

    Verbatim wording from the response

    “Twice weekly nutritional ward rounds are now taking place, led by this Consultant Gastroenterologist, and a monthly complex nutrition MDT meeting will be operational by April 2021. This will be a forum for surgeons and dietitians to meet monthly to review nutritional needs of specific patients, any refusal of treatment and the use of parental nutrition.”

    Source location

    2020-0224-Response-from-East-Surrey-Hospital-Redacted.pdf
    Page 10 · response
    Published 21 December 2020

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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 audit of nutrition training impact was delayed by COVID-19 pressures and limitations.

    Verbatim wording from the response

    “An audit to assess the impact of this training and use of the documentation is due but has been delayed due to the pressures of the COVID-19 pandemic.”

    Source location

    2020-0224-Response-from-East-Surrey-Hospital-Redacted.pdf
    Page 9 · response
    Published 21 December 2020

    Open published response

  2. 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 complete the malnutrition assessment tool

    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

    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

    Monitor documentation more closely and provide nurses with real-time feedback.

    Verbatim wording from the response

    “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:”

    Source location

    2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 7 May 2015

    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 and condense Acute Medical Unit documentation into multidisciplinary paperwork that directs care and reduces duplication.

    Verbatim wording from the response

    “Extensive and complex work is also being undertaken to”

    Source location

    2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 3 · response
    Published 7 May 2015

    Open published response

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