First reported 14 Feb 2017•Latest report 5 Jun 2026
Definition
What this concern includes
Includes failures of the dedicated dietetic service pathway affecting access to clinically necessary assessment or support, including inappropriate reliance on telephone assessment where face-to-face review is needed, inadequate appointment governance, delayed or unavailable specialist input, and insufficient out-of-hours coverage.
Not included
Excludes generic staffing, communication, funding or governance deficiencies unless they directly impair access to clinically necessary dietetic assessment or support.
Excludes non-dietetic specialist referrals and appointments, including general clinical or mental-health assessment pathways.
Excludes failures limited to nutritional care delivery where no dietetic assessment or specialist-support access deficiency is identified.
Excludes the underlying nutritional condition or outcome when no dietetic service control failure is asserted.
Reports
6
Distinct published reports
Individual concerns
6
A report can raise multiple concerns
Date range
2017–2026
First to latest report issue date
Stated actions
25
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Aneurin Bevan University LHB1
Brunswick Ward at Lindridge1
Department of Health and Social Care1
East Suffolk and North Essex NHS Foundation Trust1
Glangwili General Hospital1
NHS England1
NHS Nottingham and Nottinghamshire Integrated Care Board1
Sussex Partnership NHS Foundation Trust1
Velindre NHS Trust1
NHS trust3
Healthcare site2
Executive non-departmental public body1
Integrated care board1
Local health board1
Ministerial department1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
East Sussex
Concerns raised1
Lack of appropriately qualified dietitian provision for inpatients undergoing psychiatric care
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.2
Action
Develop safer staffing standards for Allied Health Professionals, including principles applicable to mental health services.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 6 August 2026.
Action
Continue supporting multidisciplinary and integrated approaches to care through published specifications and guidance.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 6 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
ICBs are responsible for commissioning appropriate nutritional care for psychiatric inpatients and should answer enquiries about local provision.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Providers and commissioners determine workforce models and local arrangements for dietetic provision.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Individual NHS Trusts and employers determine staffing levels and workforce composition to meet patients’ needs safely.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Lack of out-of-hours specialist dietetic service or cover for patients at CGH
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.2
Action
Undertake a project to ensure relevant ward areas receive consistent, compliant dietetic-care-planning training.
Stated by East Suffolk and North Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2026.
Action
Develop an out-of-hours escalation process for dietetic support and audit compliance regularly.
Stated by East Suffolk and North Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Weekday dietetic support, robust care plans and enteral feeding starter regimes are considered sufficient outside weekday working hours.
Stated by East Suffolk and North Essex NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Gwent
Concerns raised1
Failure to govern and monitor decisions on face to face dietetic appointments
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.9
Action
Strengthen dietetic governance through enhanced risk reporting, service-risk visibility and oversight of multidisciplinary clinical standards.
Stated by Velindre NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 October 2025.
Action
Develop dietetic assessment standards and a Standard Operating Procedure for telephone reviews and face-to-face consultations.
Stated by Velindre NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 October 2025.
Action
Finalise the dietetic Standard Operating Procedure and submit it for internal governance approval.
Stated by Velindre NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 October 2025.
Action
Implement the approved dietetic Standard Operating Procedure across relevant Velindre Cancer Service teams.
Stated by Velindre NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 October 2025.
Action
Audit the implemented dietetic Standard Operating Procedure and share learning through quality and safety governance.
Stated by Velindre NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 October 2025.
Action
Develop and update a dietetic assessment guideline defining criteria for face-to-face and remote consultations.
Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 9 October 2025.
Action
Adapt the ABUHB booking process to facilitate face-to-face review as an initial assessment.
Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 9 October 2025.
Action
Introduce a decision-making tool requiring clinicians to document the rationale for remote or in-person assessment.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 9 October 2025.
Action
Conduct annual joint audits of adherence to the transfer-of-care standard and assessment protocol, reporting findings through governance groups.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 9 October 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The actions taken are considered robust enough to prevent future deaths related to dietetic support and provision.
Stated by Velindre NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Nottinghamshire
Concerns raised1
Lack of commissioned specialist long-term dietetic support for ASD patients with ARFID symptoms
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
Review clinical cases to identify current ARFID provision and service gaps.
Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 22 November 2021.
Action
Review current ARFID service provision.
Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 22 November 2021.
Action
Develop a preferred all-ages ARFID pathway with service-delivery recommendations.
Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 22 November 2021.
Action
Obtain approval for the preferred ARFID pathway and required resources.
Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 22 November 2021.
Action
Implement the agreed all-ages ARFID pathway.
Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 22 November 2021.
Action
Undertake a skills audit and training-needs analysis across specialist and non-specialist services.
Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 22 November 2021.
Action
Explore development of expanded ARFID-related roles within primary care.
Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 22 November 2021.
Action
Explore workforce competencies around ARFID with Health Education England.
Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 22 November 2021.
Carmarthenshire and Pembrokeshire
Concerns raised1
Insufficient staffing of the acute dietetic service for timely referral response
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.
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.4
Action
Recruit substantive staff to fill acute dietetic vacancies while continuing efforts to maintain service capacity.
Stated by Hywel Dda University LHBStated in progressThe respondent said that this action was in progress when they made their response on 18 March 2019.
Action
Use locum dietetic staff to support acute service capacity while substantive recruitment continues.
Stated by Hywel Dda University LHBStated completedThe respondent said that this action was complete when they made their response on 18 March 2019.
Action
Prioritise high-risk patients for rapid dietetic referral and initiate an enhanced ward-based nutritional care pathway during staffing shortages.
Stated by Hywel Dda University LHBStated completedThe respondent said that this action was complete when they made their response on 18 March 2019.
Action
Propose increased acute dietetic establishment through additional registered dietitians and unregistered dietetic support workers.
Stated by Hywel Dda University LHBStated plannedThe respondent said that this action was planned when they made their response on 18 March 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Low numbers of suitable applicants have prevented recruitment and adequate locum cover for acute dietetic vacancies, limiting staffing capacity.
Stated by Hywel Dda University LHBUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Brighton and Hove
Concerns raised1
Failure to refer nutritionally deteriorating patients to dieticians
This report raised 25 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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Includes failures of the dedicated dietetic service pathway affecting access to clinically necessary assessment or support, including inappropriate reliance on telephone assessment where face-to-face review is needed, inadequate appointment governance, delayed or unavailable specialist input, and insufficient out-of-hours coverage.
