Recurring concern

Unreliable referrals to acute dietetic services

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First reported 29 Apr 2016•Latest report 6 Nov 2018

Definition

What this concern includes

Includes failures to recognise, initiate, communicate, act upon, track or escalate referrals to acute or hospital dietetic services when patients require dietetic assessment or support, including disagreement with a referral that is not appropriately discussed through the relevant multidisciplinary process.

Not included

  • Excludes general dietetic service capacity, appointment access or assessment-quality failures where no deficient referral process is identified.
  • Excludes failures in nutrition and hydration management where dietetic referral is not the shared unsafe condition.
  • Excludes referrals to mental-health, social-care or other specialist services unless the assertion explicitly concerns the same acute dietetic referral process.
  • Excludes failures occurring after a dietetic referral has been reliably completed and accepted, including the quality of subsequent dietetic assessment or treatment.
Reports
3

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2016–2018

First to latest report issue date

Stated actions
2

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.

Brunswick Ward at Lindridge1
Glangwili General Hospital1
Sussex Partnership NHS Foundation Trust1
University Hospitals Sussex NHS Foundation Trust1

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.

  1. Carmarthenshire and Pembrokeshire

    AI-generated summary

    Gerwyn James Thomas · 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

    Gerwyn James Thomas was admitted to hospital after a domestic fall that caused a fractured femur and required surgery. He later developed an infection and died after being readmitted to hospital three times; the inquest recorded sepsis, multi-organ failure and infected hip surgery as the medical cause of death. Concerns included delays in responding to acute dietetic referrals, insufficient staffing, and inadequate training in nutritional assessment.

    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 discuss disputed acute dietetic referrals at a multidisciplinary team meeting

    Wider context from the report

    “3. When a treating doctor identifies a need for a patient to be referred to the acute dietetic service, nursing staff should act upon this referral and in circumstances where nursing staff believe that such a referral is unnecessary this should be discussed at a multi-disciplinary team meeting. ”

    Source location

    Gerwyn James Thomas · Prevention of Future Deaths report
    Page 2 · 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 of nursing staff to act on referrals to the acute dietetic service

    Wider context from the report

    “3. When a treating doctor identifies a need for a patient to be referred to the acute dietetic service, nursing staff should act upon this referral and in circumstances where nursing staff believe that such a referral is unnecessary this should be discussed at a multi-disciplinary team meeting. ”

    Source location

    Gerwyn James Thomas · 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

    Prioritise high-risk patients for rapid dietetic referral and initiate an enhanced ward-based nutritional care pathway during staffing shortages.

    Verbatim wording from the response

    “• During November and December it has not been possible to secure adequate locum support to cover existing acute service vacancies; this has necessitated contingency arrangements to ensure patients at the greatest risk are rapidly flagged to dietetics for prioritisation and an enhanced ward based nutritional care pathway has been initiated to reduce the risk of not having timely dietetic access.”

    Source location

    2018-0342-Response-by-University-Health-Board
    Page 2 · response
    Published 18 March 2019

    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

    Require nurses to read and acknowledge the memo setting out referral responsibilities, then disseminate it through nursing leadership across other Health Board sites.

    Verbatim wording from the response

    “The Head of Nursing at Glangwili General Hospital has sent a memo to all ward staff detailing the action required by the Coroner and how they are to achieve this. She will be asking for every nurse to read the memo and sign to say they have done so and understand their responsibilities. This will then be shared with the wider nursing teams through the Heads of Nursing at the other sites across the Health Board.”

    Source location

    2018-0342-Response-by-University-Health-Board
    Page 3 · response
    Published 18 March 2019

    Open published response

  2. Brighton and Hove

    AI-generated summary

    Derek LEE · 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

    Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.

    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 refer nutritionally deteriorating patients to dieticians

    Wider context from the report

    “(8) The MUST score was properly calculated on admission but not reviewed when it was clear he was not eating. There was no evidence of any reaction to Mr Lee’s substantial weight loss. There was no referral to dieticians. They just happened to attend a multi-disciplinary meeting on the 9th May (he was admitted on the 27th April and by the 9th May had lost 10 and ¾ pounds – 4.80 kilos). Re-weighing was requested by the dieticians. It did not take place. ”

    Source location

    Derek LEE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Brighton and Hove

    AI-generated summary

    Jack MOLYNEUX · 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

    Jack MOLYNEUX was awaiting discharge to a nursing home after admission to a ward for elderly male patients, where he had dementia but no acute physical illness. The report describes concerns about inadequate care, including failures relating to mobility, hydration, nutrition, mouth care, personal hygiene, psychological wellbeing, stimulation and medication, and states that these omissions and failings contributed to his death. His death was unexpected after transfer to the nursing home, where his condition and engagement reportedly improved.

    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 monitor nutritional status and refer for dietary support

    Wider context from the report

    “Mr Jack MOLYNEUX was awaiting discharge to an appropriate Nursing Home. He was on a 19 bedded ward for elderly male patients and during that time he was not suffering from any acute physical illness, but he did however have moderately advanced mixed alzheimer’s and vascular dementia and he needed to be mobilised, he needed to be appropriately hydrated and have his nutrition maintained. He needed mouth care, he had dentures but the top plate was lost. He needed personal hygiene, he needed to have his psychological wellbeing maintained and he needed stimulation and he also needed to have his medications given to him appropriately. It was clear that he did not have mental capacity, it was clear that he could not consider the consequences of his decisions not to accept care or hydration and nutrition or his medications and yet no consideration was given of placing him on a Deprivation of Liberty Safeguarding Order. He needed, but he didn’t receive full care in respect of all the matters mentioned above. Mobility He was never helped to mobilise or to maintain the good mobility which he had when he came into hospital. He was never offered to have his out door clothes and perhaps to be assisted to go down to the hospital shop to buy a newspaper which was something he used to do every day before he came into hospital. He lost 20% of his bodyweight in the one calendar month when he was in hospital and absolutely no note was taken of this and he wasn’t referred to the dieticians until he had been in hospital for almost that full calendar month. His mouth was in such an appalling state when he moved to his nursing home that the nursing home immediately raised a safeguarding alert on the grounds of neglect. His dentures were lost and his mouth was in such a poor state that the staff, on Vallance Ward, were unaware that he even had a lower plate in his mouth. His personal hygiene was such that whilst it was noted he was washed there was no evidence whatsoever that he was ever offered a bath or shower in the four weeks of his admission. There was no evidence whatsoever that any form of stimulation was provided. There was a television by his bed but no evidence that anybody ever discussed with him whether he might like to watch anything on it. With regard to his psychological wellbeing this appeared from the evidence before me to have been completely disregarded. Finally with regard to his medications he refused all his medications on an inconsistent basis but he did take his Memantine for pretty well every day of his hospital admission apart from on a couple of occasions just before he was discharged. At the Inquest I found that whilst he had been neglected during his admission, the circumstances did not reach the required standards for a conclusion of neglect contributing his death. I believe this to be one of the most disturbing cases of sub optimal care that I have come across recently and I am not at all satisfied that this Inquest will result in any effective action being taken which is why I am concerned to follow up this matter and to ensure that all those who should know about this situation are informed. Certainly I found that the above omissions and failings contributed to Mr Molyneux’s death. When he arrived at the nursing home he came on the evening of the 25th January and on the 26th the staff at Partridge House achieved an almost miraculous transformation. He was dressed, although he needed the help of two members of staff, he was on his feet and assisted to mobilise to the toilet, he was sitting out in a bucket chair with other residents and was entertained with a film, his mouth was cleaned, the GP provided mouth wash and mouth gel which was applied. His halitosis which had been so strong that it could be smelt outside his room at Partridge House was resolved, he was smiling and reasonably responsive and was eating and drinking again and also engaged with his son, waving goodbye to him when he had visited on the 26th or 27th. His death was unexpected. Partridge House staff had hoped that whilst he would not have been able to go home he could at least have a reasonable standard of life and be enabled to be content. Finally, it is of note that an urgent DOLS was put in place on the morning of the 27th January 2016. ”

    Source location

    Jack MOLYNEUX · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026