First reported 24 Jan 2014•Latest report 22 May 2026
Definition
What this concern includes
Includes failures to communicate, transfer, acknowledge or maintain patient-specific nutritional requirements and restrictions, including nil-by-mouth status, PEG-feeding information and comparable nutrition-related safety instructions, across hospital, care-home and other care settings.
Not included
Excludes general communication, handover or record-keeping failures where no patient-specific nutritional requirement or restriction is involved.
Excludes failures to assess nutritional need or provide food, fluids, supplements or feeding after the relevant requirements were reliably communicated.
Excludes food-hygiene, food-provider, dysphagia and choking controls unless the asserted deficiency is specifically the communication of nutritional requirements.
Excludes failures involving clinical decisions about nutrition where the information was communicated reliably and the problem was the decision itself.
Reports
12
Distinct published reports
Individual concerns
13
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
27
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Barts Health NHS Trust1
Betsi Cadwaladr University LHB1
Cwm Taf Morgannwg University Local Health Board1
Gloucestershire Hospitals NHS Foundation Trust1
Highgrove Rest Home1
New Park Residential Home1
Northampton General Hospital1
Royal Devon University Healthcare NHS Foundation Trust1
Sheffield Teaching Hospitals NHS Foundation Trust1
Somerset NHS Foundation Trust1
Stockton Care Limited1
Stoke-on-Trent City Council1
the Royal Orthopaedic Hospital NHS Foundation Trust1
Welsh Ambulance Services NHS Trust1
NHS trust7
Local health board2
Residential care home2
English unitary authority1
Healthcare site1
Private limited company1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Somerset
Concerns raised2
Failure to clearly document and communicate a patient’s nil by mouth status reported by family on the ward
Failure to effectively communicate patients’ nil by mouth status from the emergency department during transfer to a ward
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Strengthen documentation, escalation, clinical review, and closed-loop communication of family-raised risks such as nil-by-mouth status.
Stated by NHS Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 August 2026.
Action
Review and standardise bedside safety information, alerts, safety huddles, briefings, and handovers to improve visibility of nil-by-mouth status.
Stated by NHS Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 August 2026.
Action
Develop a Trust-wide SBAR handover template with mandatory dietary-status fields identifying nil-by-mouth status as a critical safety parameter.
Stated by NHS Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 August 2026.
Action
Embed a transfer safety pause requiring transferring and receiving staff to confirm key risks, including nil-by-mouth status, before handover completion.
Stated by NHS Somerset NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 August 2026.
Action
Review patient-transfer standard operating procedures for appropriate staffing, equipment, and communication processes.
Stated by NHS Somerset NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 August 2026.
Action
Conduct After Action Reviews of communication and handover incidents under Patient Safety Incident Response Framework principles.
Stated by NHS Somerset NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 August 2026.
Northamptonshire
Concerns raised1
Failure to establish and communicate patients’ gluten and dairy intolerance status
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Record allergies and intolerances consistently in Nevercentre and discuss allergy status during daily Board Rounds.
Stated by University Hospitals of Northamptonshire NHS GroupStated completedThe respondent said that this action was complete when they made their response on 24 February 2026.
Teesside and Hartlepool
Concerns raised1
Failure to effectively communicate nil-by-mouth and PEG-feeding concerns to care staff
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Communicate the coroner’s concerns and effective communication requirements to all staff.
Stated by Stockton Care LimitedStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Schedule further staff meetings for employees who did not attend the 22 March 2024 meeting.
Stated by Stockton Care LimitedStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Implement an upgraded cloud-based electronic documentation system displaying residents’ risks, alerts and special instructions.
Stated by Stockton Care LimitedStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Maintain robust day and night handovers covering resident risks, complaints and concerns, with management oversight and audit monitoring.
Stated by Stockton Care LimitedStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Ensure detailed risk assessments and care plans for residents receiving modified diets or fluids.
Stated by Stockton Care LimitedStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2024.
Exeter and Greater Devon
Concerns raised1
Failure of discharge summaries to clearly communicate target fluid intake
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Use Epic’s Hospital Course function to build discharge summaries from clinicians’ real-time inpatient documentation.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 September 2023.
Action
Use bespoke discharge-summary templates for complex patient groups to clarify pertinent information and follow-up instructions.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 September 2023.
Action
Maintain a four-day junior-doctor rota in Medicine to reduce cross-cover and improve staffing consistency for discharge documentation.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 September 2023.
Action
Review use of the After Visit Summary across inpatient and outpatient services through an established working group.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 September 2023.
Action
Produce guidance and standard operating procedures for ward teams following the After Visit Summary review.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 September 2023.
Action
Review community-hospital staffing to develop a more robust, consistent medical team with specialty-doctor and Advanced Clinical Practitioner oversight.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 September 2023.
Action
Relaunch the Trust-wide discharge-summary working group with primary-care representation to refine discharge processes and communication.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust considers reviewing every discharge letter by a consultant infeasible because of resource demands, unclear responsibility, delays and risks of error.
Stated by Royal Devon University Healthcare NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
North Wales (East and Central)
Concerns raised1
Failure to communicate nil-by-mouth status to visitors
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Blackpool and the Fylde
Concerns raised1
Failure to maintain care plans with accurate nutritional requirements
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.
South Wales Central
Concerns raised1
Lack of a protocol to inform relevant staff when an emergency ambulance is awaited so that appropriate patients are kept nil by mouth
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Revise the process for managing patients awaiting emergency ambulances, specifying nil-by-mouth instructions, documentation, and notification responsibilities.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 22 December 2021.
South Yorkshire (West)
Concerns raised1
Delays in displaying nutritional requirements at the bedside
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.
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.3
Action
Update, disseminate and make available the ward meal-service SOP covering mealtime safety huddles and dietary requirements.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.
Action
Record IDDSI eating, drinking, texture and fluid requirements on the Electronic Whiteboard and populate multidisciplinary handover sheets.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.
Action
Provide wards with IDDSI diet signage and related patient information forms, including visible IDDSI level descriptions.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 January 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
COVID-19 operational pressures prevent implementing all planned safety changes in the near future.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Gloucestershire
Concerns raised1
Failure to communicate patients' nutritional status effectively to hospital staff during admission
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Run safety huddles on selected wards to disseminate patient-safety information and review patients’ nutritional status, including NBM changes.
Stated by Gloucestershire Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The concern concerns a one-off failure to use signage, not a failure to assess or manage the patient’s nutritional needs.
Stated by Gloucestershire Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing nutritional-management systems are appropriate, available and in use to safely manage patients’ nutritional care.
Stated by Gloucestershire Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Worcestershire
Concerns raised1
Failure of communication during inter-hospital transfers
This report raised 4 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.2
Action
Refresh and reaffirm emergency patient receiving and first-line management processes, including a ring-fenced spinal emergency bed and HDU escalation route.
Stated by the Royal Orthopaedic Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2015.
Action
Refresh and simplify proforma-based documentation for nursing and medical multidisciplinary teams.
Stated by the Royal Orthopaedic Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2015.
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Includes failures to communicate, transfer, acknowledge or maintain patient-specific nutritional requirements and restrictions, including nil-by-mouth status, PEG-feeding information and comparable nutrition-related safety instructions, across hospital, care-home and other care settings.
