22 May 2026 Jacqueline Marie Antoinette Frehe · Prevention of Future Deaths report Somerset
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Concerns raised 3
Failure to clearly document and communicate a patient’s nil by mouth status reported by family on the ward View source Failure of ward staff to question a patient’s nil by mouth status when receiving a patient with dysphagia and suspected aspiration pneumonia View source Failure to effectively communicate patients’ nil by mouth status from the emergency department during transfer to a ward View source
Linked response
NHS Somerset NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
NHS Somerset NHS Foundation Trust
Strengthen documentation, escalation, clinical review, and closed-loop communication of family-raised risks such as nil-by-mouth status.
View source
NHS Somerset NHS Foundation Trust
Review and standardise bedside safety information, alerts, safety huddles, briefings, and handovers to improve visibility of nil-by-mouth status.
View source
NHS Somerset NHS Foundation Trust
Deliver ward-based dysphagia and aspiration-risk education and promote IDDSI e-learning for clinical staff.
View source
NHS Somerset NHS Foundation Trust
Develop a Trust-wide SBAR handover template with mandatory dietary-status fields identifying nil-by-mouth status as a critical safety parameter.
View source
NHS Somerset NHS Foundation Trust
Embed a transfer safety pause requiring transferring and receiving staff to confirm key risks, including nil-by-mouth status, before handover completion.
View source
NHS Somerset NHS Foundation Trust
Review patient-transfer standard operating procedures for appropriate staffing, equipment, and communication processes.
View source
NHS Somerset NHS Foundation Trust
Conduct After Action Reviews of communication and handover incidents under Patient Safety Incident Response Framework principles.
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AI-generated summary
Jacqueline Marie Antoinette Frehe · 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
Jacqueline Marie Antoinette Frehe, aged 97, was admitted to hospital with swallowing difficulties, vomiting and suspected aspiration pneumonia. Her nil by mouth status was not communicated to ward staff, and she was given food and drink, after which she vomited, deteriorated significantly and died within about two hours. The concerns related to communication and documentation of nil by mouth status and checking this status when patients with dysphagia and suspected aspiration pneumonia arrive on the ward.
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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 clearly document and communicate a patient’s nil by mouth status reported by family on the ward
Wider context from the report “I heard evidence from the Ward Manager. I was not satisfied that sufficient steps had been taken to ensure that:
1. patients’ nil by mouth status is effectively communicated from the emergency department on transfer of patients to a ward setting; and
2. communication of a patient’s nil by mouth status by family is clearly documented and communicated on the ward ; and
3. ward staff question a patient’s nil by mouth status on receiving a patient with a presentation of dysphagia and suspected aspiration pneumonia.
” Source location Jacqueline Marie Antoinette Frehe · 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 of ward staff to question a patient’s nil by mouth status when receiving a patient with dysphagia and suspected aspiration pneumonia
Wider context from the report “I heard evidence from the Ward Manager. I was not satisfied that sufficient steps had been taken to ensure that:
1. patients’ nil by mouth status is effectively communicated from the emergency department on transfer of patients to a ward setting; and
2. communication of a patient’s nil by mouth status by family is clearly documented and communicated on the ward; and
3. ward staff question a patient’s nil by mouth status on receiving a patient with a presentation of dysphagia and suspected aspiration pneumonia .
” Source location Jacqueline Marie Antoinette Frehe · 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 effectively communicate patients’ nil by mouth status from the emergency department during transfer to a ward
Wider context from the report “I heard evidence from the Ward Manager. I was not satisfied that sufficient steps had been taken to ensure that:
1. patients’ nil by mouth status is effectively communicated from the emergency department on transfer of patients to a ward setting ; and
2. communication of a patient’s nil by mouth status by family is clearly documented and communicated on the ward; and
3. ward staff question a patient’s nil by mouth status on receiving a patient with a presentation of dysphagia and suspected aspiration pneumonia.
” Source location Jacqueline Marie Antoinette Frehe · 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 Strengthen documentation, escalation, clinical review, and closed-loop communication of family-raised risks such as nil-by-mouth status.
Verbatim wording from the response “To address this, we are strengthening expectations for staff to clearly document, escalate, and act upon concerns raised by families. This will include:” Source location Response from Somerset 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 Review and standardise bedside safety information, alerts, safety huddles, briefings, and handovers to improve visibility of nil-by-mouth status.
Verbatim wording from the response “4. Visual Identification and Safety Communication” Source location Response from Somerset 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 Deliver ward-based dysphagia and aspiration-risk education and promote IDDSI e-learning for clinical staff.
Verbatim wording from the response “We are continuing to strengthen education and training for clinical staff in relation to dysphagia, aspiration risk, and safe management of nutrition and hydration. This includes targeted ward-based teaching and promotion of the International Dysphagia Diet Standardisation Initiative (IDDSI) e-learning programme, delivered in collaboration with our speech and language therapy colleagues. We would aim to have 90% of staff within the service group trained within the next 6 months. Our clinical skills facilitators are promoting this training alongside delivery of their snack box training in conjunction with our hydration and nutrition team.” Source location Response from Somerset 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 Trust-wide SBAR handover template with mandatory dietary-status fields identifying nil-by-mouth status as a critical safety parameter.
Verbatim wording from the response “1. Standardisation of Emergency Department to Ward Handover” Source location Response from Somerset 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 Embed a transfer safety pause requiring transferring and receiving staff to confirm key risks, including nil-by-mouth status, before handover completion.
Verbatim wording from the response “In addition, we plan to embed a ‘safety pause’ within the transfer process, requiring both transferring and receiving staff to confirm key patient risks, including NBM status, before handover is completed. This will be supported by clearer accountability, including named individuals responsible for providing and receiving handover information.” Source location Response from Somerset 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 Review patient-transfer standard operating procedures for appropriate staffing, equipment, and communication processes.
Verbatim wording from the response “This programme also includes a review of our standard operating procedures for patient transfers to ensure that appropriate staffing, equipment, and communication processes are consistently in place.” Source location Response from Somerset 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 Conduct After Action Reviews of communication and handover incidents under Patient Safety Incident Response Framework principles.
Verbatim wording from the response “The Trust has strengthened its approach to incidents involving communication/ sharing of patient information, and handover by undertaking After Action Reviews (AARs) in accordance with the principles of Patient Safety Incident Response Framework (PSIRF). This approach supports the rapid identification of learning, promotes a systems-based understanding of the factors influencing practice, and enables proportionate improvement actions to be implemented at the point of care. Learning derived from AARs is also aggregated and considered within wider Quality Improvement workstreams, ensuring that themes relating to information sharing and ward-level handover arrangements inform our longer-term organisational improvement and risk reduction strategies This work is being done in conjunction with our Patient Safety Faculty.” Source location Response from Somerset NHS Foundation Trust
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16 Dec 2025 Walter Perukeno POLLYN · Prevention of Future Deaths report Kent and Medway
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Concerns raised 1
Failure to prevent water access for patients who are nil by mouth View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Medway NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Medway NHS Foundation Trust
Conduct recurring Trust-wide audits of nil-by-mouth care and escalate findings through safety and quality governance.
View source
Medway NHS Foundation Trust
Provide targeted face-to-face nil-by-mouth, supervised-water and aspiration-risk training, reinforced through care study days, handovers and safety huddles.
View source
Medway NHS Foundation Trust
Standardise bedside signage, tracking-board flags, water restrictions and documentation prompts for nil-by-mouth patients.
View source
Medway NHS Foundation Trust
Introduce a structured nil-by-mouth checklist for non-procedural patients.
View source
Medway NHS Foundation Trust
Explore automated electronic patient-record alerts for conflicting nil-by-mouth documentation and recorded water provision.
View source
Medway NHS Foundation Trust
Reinforce patient safety outcomes, rather than task completion, as the measure of success.
View source See 3 more actions
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AI-generated summary
Walter Perukeno POLLYN · 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
Walter Pollyn was admitted after an unwitnessed fall and increased confusion, tested positive for Covid-19, and was later placed nil by mouth because of oropharyngeal dysphagia. Water was repeatedly left within his reach, and he aspirated water on 24 July 2024 before his condition deteriorated. He died in hospital on 16 August 2024; the immediate cause was multifactorial pneumonia, including aspiration pneumonia. The principal concerns were repeated staff failure to follow the nil-by-mouth instruction and possible underlying attitudinal and record-keeping issues that allowed unsupervised access to water to persist.
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× 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 prevent water access for patients who are nil by mouth
Wider context from the report “(1) Having been made 'nil by mouth', the evidence was that this was well documented in Mr Pollyn's records, a sign indicating that he was nil by mouth was placed above his bed, and the board within the ward kitchen was also updated. Despite this, the records indicate that numerous members of nursing staff ensured that water was placed at Mr Pollyn's bedside (which would be standard practice were Mr Pollyn not 'nil by mouth' at the time). While the Trust has updated the relevant policies and sought to disseminate messaging to staff in this regard, I was not reassured that this is solely a matter of policy. The number of staff involved and the period of time over which the issue of unsupervised access to water persisted is potentially suggestive of underlying attitudinal issues.
” Source location Walter Perukeno POLLYN · 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 Conduct recurring Trust-wide audits of nil-by-mouth care and escalate findings through safety and quality governance.
Verbatim wording from the response “A detailed Trust-wide ‘nil by mouth’ care improvement action plan has been developed and implemented to directly address the potential gaps identified during the Inquest. This action plan includes:” Source location Response from Medway 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 Provide targeted face-to-face nil-by-mouth, supervised-water and aspiration-risk training, reinforced through care study days, handovers and safety huddles.
Verbatim wording from the response “• Targeted education and training to enhance staff understanding of ‘nil by mouth’ status, supervised sips of water, and the clinical risks related to aspiration. This training is provided face-to-face alongside nutrition and hydration education, reinforced through Harm-Free Care study days, daily ward handovers, and safety huddles. Training compliance is tracked via a central training database.” Source location Response from Medway 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 Standardise bedside signage, tracking-board flags, water restrictions and documentation prompts for nil-by-mouth patients.
Verbatim wording from the response “• Clear visual controls and environmental safeguards, including revised bedside signage, tracking board flags, and standardised prompts, aim to reduce reliance on memory or assumptions. These include standardised bedside signage stating ‘supervised water only,’ removal of unsupervised water jugs, visible ‘nil by mouth’ indicators on electronic patient tracking boards, and clear documentation prompts. All signage and visual controls are being standardised through the Fundamental Standards of Care Group.” Source location Response from Medway 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 Introduce a structured nil-by-mouth checklist for non-procedural patients.
Verbatim wording from the response “• Introduction of a structured ‘nil by mouth’ checklist for non-procedural patients to minimise practice variations and ensure key safety steps are not overlooked.” Source location Response from Medway 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 Explore automated electronic patient-record alerts for conflicting nil-by-mouth documentation and recorded water provision.
Verbatim wording from the response “• Digital system improvements, including exploration of automated electronic patient record (EPR) alerts to identify documentation conflicts, such as when provision of water is recorded for a patient marked as ‘nil by mouth’.” Source location Response from Medway 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 Reinforce patient safety outcomes, rather than task completion, as the measure of success.
Verbatim wording from the response “These insights have informed a series of high-impact actions already in progress, including:” Source location Response from Medway NHS Foundation Trust
Open published response
14 Oct 2025 William Roath · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Failure of doctors to document Nil by Mouth instructions pending SALT assessment View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring 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
William Roath · 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
William Roath was admitted to hospital after falling down concrete steps and sustaining skull fractures and a traumatic brain injury. He subsequently developed aspiration pneumonia and died at Worcestershire Royal Hospital on 12 December 2024. The principal concern was that, after staff identified difficulty swallowing, there was a five-day delay in referral for specialist assessment and oral feeding continued, contributing to the development or worsening of aspiration pneumonia; the report also identified a lack of action to prevent similar errors by doctors at the Trust.
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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 of doctors to document Nil by Mouth instructions pending SALT assessment
Wider context from the report “While Mr. Roath was being treated for a traumatic brain injury at the Queen Elizabeth Hospital, Birmingham, a nurse documented on 20.11.24 that he was coughing and spluttering when receiving food and documented that staff were “not to continue to feed patient”. Mr. Roath was then reviewed by a doctor that same day, who documented that there should be a SALT ( Speech & Language Therapy Team ) assessment, but did not record any advice about whether Mr. Roath should remain Nil by Mouth in the meantime . A referral was not made to the SALT team for another 5 days, during which time nursing staff continued to feed Mr. Roath orally. The consultant who gave evidence about the University Hospitals Birmingham NHS Foundation Trust’s ( the Trust’s ) own investigation into this issue told the inquest:
(a) Any member of staff can make a referral to the SALT team, and in this case it should have been clearly agreed and set out who would be making the referral recommended on 20.11.24;
(b) The reviewing doctor should also have documented that Mr. Roath was to be made Nil by Mouth until a further SALT assessment had been carried out ;
(c) Continued oral feeding between 20-25.11.24 contributed to the development/worsening of Mr. Roath’s aspiration pneumonia which was diagnosed on 21.11.24;
(d) The failure promptly to assess and treat the worsening in Mr. Roath’s swallowing ability which was identified on 20.11.24 amounted to a failure to provide a basic level of care.
Having heard evidence from a Senior Sister on Ward 409, where Mr. Roath was treated throughout his admission, I was satisfied that sufficient measures had been taken to try to ensure that nursing and healthcare staff did not repeat the omissions which had been identified at the inquest.
When the same question was asked of the consultant in respect of doctors at the Trust, the inquest was told:
“a Trust-wide communication will go out to all members of staff that SALT referrals in cases of aspiration can be made by any healthcare professional, and should be made by the professional who recognizes a risk of aspiration.”
I am therefore concerned that, so far as doctors at the Trust are concerned, nearly 12 months after the relevant events, no action has yet been taken to try to ensure that the errors made by the doctor who reviewed Mr. Roath on 20.11.24 are not repeated .
” Source location William Roath · Prevention of Future Deaths report
Open source report
14 Mar 2024 Victor Valentine Costello · Prevention of Future Deaths report Teesside and Hartlepool
View report summary
Concerns raised 1
Failure to effectively communicate nil-by-mouth and PEG-feeding concerns to care staff View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Stockton Care Limited
Communicate the coroner’s concerns and effective communication requirements to all staff.
View source
Stockton Care Limited
Schedule further staff meetings for employees who did not attend the 22 March 2024 meeting.
View source
Stockton Care Limited
Implement an upgraded cloud-based electronic documentation system displaying residents’ risks, alerts and special instructions.
View source
Stockton Care Limited
Maintain robust day and night handovers covering resident risks, complaints and concerns, with management oversight and audit monitoring.
View source
Stockton Care Limited
Ensure detailed risk assessments and care plans for residents receiving modified diets or fluids.
View source See 2 more actions
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AI-generated summary
Victor Valentine Costello · 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
Victor Valentine Costello, a resident at Primrose Court Nursing Home, was taken to hospital on 17 February 2020 and died there six days later from naturally occurring disease. Concerns were raised that information about his drinking water despite being nil by mouth and PEG fed was not effectively communicated to staff.
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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 effectively communicate nil-by-mouth and PEG-feeding concerns to care staff
Wider context from the report “Mr Costello was nil by mouth and PEG fed. His family raised concerns that Mr Costello had told them he had been drinking water from the taps in his bathroom. Evidence was given at the inquest by the Nursing Home Manager that such concerns were communicated to all staff. However, further evidence given at the inquest showed that such communication was not effective (the nurse in charge and the two care assistants who were on duty on the morning Mr Costello was taken to hospital, all denied being aware of such concerns ).
” Source location Victor Valentine Costello · 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 Communicate the coroner’s concerns and effective communication requirements to all staff.
Verbatim wording from the response “Actions | Responsible people | Time Scale
We have communicated to all staff the coroner’s concern and the importance of effective communication including use of the electronic documentation system (see item below), daily handover sheets and verbal communication between shifts. | Chief Executive- ████████
Operation Director- ████████
Home Manger- ████████
All nursing and senior staff | We had an all staff meeting on 22nd March 2024.
We will schedule further meetings for those staff who did not attend.” Source location Response from Stockton Care LTD
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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 Schedule further staff meetings for employees who did not attend the 22 March 2024 meeting.
Verbatim wording from the response “Actions | Responsible people | Time Scale
We have communicated to all staff the coroner’s concern and the importance of effective communication including use of the electronic documentation system (see item below), daily handover sheets and verbal communication between shifts. | Chief Executive- ████████
Operation Director- ████████
Home Manger- ████████
All nursing and senior staff | We had an all staff meeting on 22nd March 2024.
We will schedule further meetings for those staff who did not attend.” Source location Response from Stockton Care LTD
Open published response
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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 an upgraded cloud-based electronic documentation system displaying residents’ risks, alerts and special instructions.
Verbatim wording from the response “We are implementing an upgraded cloud based electronic documentation system where staff can easily look at each residents’ risks, alerts, and special instructions. | Chief Executive- ████████
Operation Director- ████████
Home Manger- ████████
All nursing and senior staff | The full implementation of the new electronic documentation system will be on 1st June 2024.” Source location Response from Stockton Care LTD
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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 Maintain robust day and night handovers covering resident risks, complaints and concerns, with management oversight and audit monitoring.
Verbatim wording from the response “We have made sure that effective and robust handovers take place between day and night staff to include explaining risks associated with | Home Manger- ████████
All nursing and senior staff, | Ongoing.” Source location Response from Stockton Care LTD
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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 Ensure detailed risk assessments and care plans for residents receiving modified diets or fluids.
Verbatim wording from the response “The management will monitor handovers as part of our regular audits. We are also making sure that for all residents who are on modified diet and fluids, their risk assessments and care plans are detailed and will be shared with next of kin to make sure all the information is correct. | ████████- Operations Director, will keep their record of our checks and any shortfalls will be addressed. | On going” Source location Response from Stockton Care LTD
Open published response
Concerns raised 1
Failure to communicate nil-by-mouth status to visitors View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring 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
Philip Hawkins · 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
Philip Hawkins, aged 97, suffered a fall at home on 18 March 2023, was transferred by ambulance to hospital, and died on 23 March 2023. Concerns included delays in being admitted and allocated a bed, insufficient staffing, inability to provide care, gaps in nursing documentation, and failures in aspects of assessment and treatment.
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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 communicate nil-by-mouth status to visitors
Wider context from the report “Care Concerns in the ED
4. On 18.03.22 at 02:49 there was no space for a nurse to attend to Mr Hawkins’ personal care needs or assess his pressure areas.
5. On 19.03.23 at 12:18, Mr Hawkins needed ‘repeat bloods’ but this was never done nor highlighted to clinicians.
6. On 19.03.23 at 00:31 Mr Hawkins was given oxygen but there are no nursing notes to indicate why or whether this was discussed with a clinician.
7. There is no written nursing documentation in relation to Mr Hawkins’ care from 21:52 on 19.03.23.
8. Mr Hawkins was nil by mouth but this was not made known to visitors who fed him .
” Source location Philip Hawkins · Prevention of Future Deaths report
Open source report
Concerns raised 1
Inadequate staff training and awareness on Nil by Mouth management for patients requiring regular medication View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring 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
Terence Bradfield · 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 Bradfield entered Derriford Hospital on 1 December 2013 with gastric bleeding and died on 17 December 2013, primarily from the consequences of his gastrointestinal bleed. The report raised concerns that his long-term steroid medication was not given or adequately managed, including when he was vomiting, and about staff training and the absence of policies for steroid management and “Nil by Mouth” patients with co-morbidities.
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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 Inadequate staff training and awareness on Nil by Mouth management for patients requiring regular medication
Wider context from the report “(1) They are :
1. Mr. Bradfield was not given his steroids on 2.12.13
2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4th and 5th December 2013 when Mr. Bradfield had reported vomiting
3. Mr. Bradfield was not put on a stress dose of steroids whilst in Derriford hospital
4. The awareness and training of staff on the issue of steroid management.
5. The lack of a policy on the administration of steroids generally and their use in situations where a number of co – morbidities are present despite this death having arisen in 2013.
6. The training and awareness of staff on the meaning of “Nil by Mouth “ in patients who are suffering from a number of co –morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures .
” Source location Terence Bradfield · Prevention of Future Deaths report
Open source report
24 Jan 2014 Bertha CRAY · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to prevent inadvertent alteration of ‘nil by mouth’ signage View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Barts Health NHS Trust
Stop using amendable double-sided nil-by-mouth signs and issue signs carrying the same instruction on both sides.
View source
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AI-generated summary
Bertha CRAY · 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
Bertha CRAY’s oesophagus was perforated during an upper-gastrointestinal endoscopy, and she later died from bronchopneumonia resulting from the perforation and surgical treatment. The report raised concerns about the possible inadvertent alteration or replacement of ‘nil by mouth’ signage, uncertainty about how this occurred, and the lack of demonstrated action following the 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 prevent inadvertent alteration of ‘nil by mouth’ signage
Wider context from the report “(1) On the account provided by the nursing staff, it is possible that inadvertent alteration of ‘nil by mouth’ signage could occur in the future , due to the apparent ease with which a double-sided sign can be turned and lack of action taken as a consequence of this clinical incident.
” Source location Bertha CRAY · 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 Stop using amendable double-sided nil-by-mouth signs and issue signs carrying the same instruction on both sides.
Verbatim wording from the response “During the investigation, qualified nursing staff confirmed that the use of double-sided ‘nil-by-mouth’/‘sips of water’ signs at the bedside was not the usual practice in the Trust. In this particular case, ‘sips of water’ had been written on the other side of the sign. This practice will now stop and new signs issued with the same instruction on both sides, so there is no option to amend the signs by writing on them.” Source location 2014-0037-Response-by-Barts-Health-NHS
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.