LESLEY MAWBY · Prevention of Future Deaths report

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Issued 18 Jun 2021•Manchester South

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
2

Of 1 recipient

Stated actions
18

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Residual staffing shortages in the dietetic team
    Part of recurring concern: Insufficient dietetic staffing capacity for timely patient care

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.18

  1. Stockport NHS Foundation Trust

    Review dietetic staffing risks monthly through divisional governance and the Risk Management Committee.

  2. Stockport NHS Foundation Trust

    Develop and progress a business case for increased nutrition and dietetic staffing through Trust governance.

  3. Stockport NHS Foundation Trust

    Arrange training for substantive staff to address identified skill gaps.

  4. Stockport NHS Foundation Trust

    Review ward care plans and referral criteria.

  5. Stockport NHS Foundation Trust

    Provide weekend out-of-hours enteral and parenteral feeding guidance to ensure patients receive appropriate nutrition pending dietetic review.

  6. Stockport NHS Foundation Trust

    Combine community and acute nutrition and dietetic staffing establishments to enable flexible cross-service working.

  7. Stockport NHS Foundation Trust

    Use a task-and-finish group to review processes and identify service improvements.

  8. Stockport NHS Foundation Trust

    Allocate highest-priority new and follow-up patients to available staff under senior-dietitian oversight.

  9. Stockport NHS Foundation Trust

    Participate in NHS benchmarking and benchmark the referral process against other Greater Manchester trusts.

  10. Stockport NHS Foundation Trust

    Complete a dietitian job-planning exercise and benchmark staffing against British Dietetic Association recommendations.

  11. Stockport NHS Foundation Trust

    Review the skill mix and examine non-registered staff roles and responsibilities.

  12. Stockport NHS Foundation Trust

    Recruit to additional nutrition and dietetic posts to address identified staffing needs.

  13. Stockport NHS Foundation Trust

    Use a streamlined referral spreadsheet recording assessment due dates, follow-up review dates and review reasons.

  14. Stockport NHS Foundation Trust

    Report missed triage review timeframes through Datix and review incidents weekly at the Incident Review Group.

  15. Stockport NHS Foundation Trust

    Monitor caseloads regularly to ensure patients are prioritised and seen within appropriate timescales.

  16. Stockport NHS Foundation Trust

    Combine specialist acute caseloads and prioritise them across the service.

  17. Stockport NHS Foundation Trust

    Conduct twice-daily senior-dietitian triage and prioritise referrals using referral criteria and clinical judgement.

  18. NHS Greater Manchester Integrated Care Board

    Request a commissioning-led review to assure consistent delivery of service levels.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Stockport NHS Foundation Trust

    Existing out-of-hours guidance is considered sufficient to ensure appropriate nutrition and prevent weekend delays without routine dietetic review.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. Stockport NHS Foundation Trust

    The dietetic service cannot provide seven-day cover because it is not commissioned to operate seven days.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Residual staffing shortages in the dietetic team

Wider context from the report

“(1) It is a matter of concern that there are residual staffing shortages in the dietetic team leading to delays in assessments on weekdays and meaning weekend cover cannot be provided. ”

Is this part of a recurring concern?

Yes — Insufficient dietetic staffing capacity for timely patient care.

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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 dietetic staffing risks monthly through divisional governance and the Risk Management Committee.

Verbatim wording from the response

“Business Case developed – Therapies Staffing A risk assessment in respect of the dietetic staffing was completed in October 2020 and a detailed review has been completed. The risk to patients due to the staffing establishment and capacity in the team is reviewed monthly by the divisional team and by the executives at the Risk Management Committee.”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 2 · response
Published 28 June 2021

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

Develop and progress a business case for increased nutrition and dietetic staffing through Trust governance.

Verbatim wording from the response

“A business case for therapy staffing is under development and is progressing through the Trust governance process. The Business Case is for increased support for therapy provision regarding nutrition and dietetics. It provides an option appraisal with a phased implementation of both qualified and non-qualified workforce, identifying high risk areas and allowing for training opportunities. However, the Trust has recognised the need for additional resource and is already recruiting to the posts. We would be happy to update you on progress in the future, if required.”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 2 · response
Published 28 June 2021

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

Arrange training for substantive staff to address identified skill gaps.

Verbatim wording from the response

“• A gap analysis has been completed and current gap in skillset identified. Training of substantive staff is to be arranged.”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 2 · response
Published 28 June 2021

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 ward care plans and referral criteria.

Verbatim wording from the response

“Job planning and benchmarking There is a dietitian job planning exercise underway with Project Management Office (PMO) support, due for completion in September 2021. This will be benchmarked against the British Dietetic Association (BDA) Dietetic Caseload Recommendations. The service is also participating in an NHS benchmarking exercise. A task and finish group has been set up to review processes and identify improvements. In addition, the service is benchmarking the referral process with other Greater Manchester trusts and there is an ongoing review of ward care plans /referral criteria. The current skill mix is also in the process of review with the roles and responsibilities of non-registered staff being examined.”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 2 · response
Published 28 June 2021

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

Provide weekend out-of-hours enteral and parenteral feeding guidance to ensure patients receive appropriate nutrition pending dietetic review.

Verbatim wording from the response

“7 day provision The service is not commissioned to run over 7 days and this is in line with other Greater Manchester NHS Trusts. The target times for reviewing patients are in line with priority categories. However, there is weekend provision currently in place in the form of out of hours guidance, available for all staff, which includes feeding regimes for patients on enteral feeding or parenteral feeding: this supports appropriate nutrition being available over weekends ensuring no delays. A copy is attached in Appendix B and C. The subsequent”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 1 · response
Published 28 June 2021

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

Combine community and acute nutrition and dietetic staffing establishments to enable flexible cross-service working.

Verbatim wording from the response

“Additional measures implemented by the Dietetic Service to mitigate the risk are as follows:”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 2 · response
Published 28 June 2021

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

Use a task-and-finish group to review processes and identify service improvements.

Verbatim wording from the response

“Job planning and benchmarking There is a dietitian job planning exercise underway with Project Management Office (PMO) support, due for completion in September 2021. This will be benchmarked against the British Dietetic Association (BDA) Dietetic Caseload Recommendations. The service is also participating in an NHS benchmarking exercise. A task and finish group has been set up to review processes and identify improvements. In addition, the service is benchmarking the referral process with other Greater Manchester trusts and there is an ongoing review of ward care plans /referral criteria. The current skill mix is also in the process of review with the roles and responsibilities of non-registered staff being examined.”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 2 · response
Published 28 June 2021

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

Allocate highest-priority new and follow-up patients to available staff under senior-dietitian oversight.

Verbatim wording from the response

“The Dietitian will review the highest priority patients from new and follow up patients and allocate those patients in order based on the criteria and clinical judgement to the staff available. The process is overseen by a senior Dietitian.”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 2 · response
Published 28 June 2021

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

Participate in NHS benchmarking and benchmark the referral process against other Greater Manchester trusts.

Verbatim wording from the response

“Job planning and benchmarking There is a dietitian job planning exercise underway with Project Management Office (PMO) support, due for completion in September 2021. This will be benchmarked against the British Dietetic Association (BDA) Dietetic Caseload Recommendations. The service is also participating in an NHS benchmarking exercise. A task and finish group has been set up to review processes and identify improvements. In addition, the service is benchmarking the referral process with other Greater Manchester trusts and there is an ongoing review of ward care plans /referral criteria. The current skill mix is also in the process of review with the roles and responsibilities of non-registered staff being examined.”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 2 · response
Published 28 June 2021

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

Complete a dietitian job-planning exercise and benchmark staffing against British Dietetic Association recommendations.

Verbatim wording from the response

“Job planning and benchmarking There is a dietitian job planning exercise underway with Project Management Office (PMO) support, due for completion in September 2021. This will be benchmarked against the British Dietetic Association (BDA) Dietetic Caseload Recommendations. The service is also participating in an NHS benchmarking exercise. A task and finish group has been set up to review processes and identify improvements. In addition, the service is benchmarking the referral process with other Greater Manchester trusts and there is an ongoing review of ward care plans /referral criteria. The current skill mix is also in the process of review with the roles and responsibilities of non-registered staff being examined.”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 2 · response
Published 28 June 2021

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 the skill mix and examine non-registered staff roles and responsibilities.

Verbatim wording from the response

“Job planning and benchmarking There is a dietitian job planning exercise underway with Project Management Office (PMO) support, due for completion in September 2021. This will be benchmarked against the British Dietetic Association (BDA) Dietetic Caseload Recommendations. The service is also participating in an NHS benchmarking exercise. A task and finish group has been set up to review processes and identify improvements. In addition, the service is benchmarking the referral process with other Greater Manchester trusts and there is an ongoing review of ward care plans /referral criteria. The current skill mix is also in the process of review with the roles and responsibilities of non-registered staff being examined.”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 2 · response
Published 28 June 2021

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

Recruit to additional nutrition and dietetic posts to address identified staffing needs.

Verbatim wording from the response

“A business case for therapy staffing is under development and is progressing through the Trust governance process. The Business Case is for increased support for therapy provision regarding nutrition and dietetics. It provides an option appraisal with a phased implementation of both qualified and non-qualified workforce, identifying high risk areas and allowing for training opportunities. However, the Trust has recognised the need for additional resource and is already recruiting to the posts. We would be happy to update you on progress in the future, if required.”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 2 · response
Published 28 June 2021

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

Use a streamlined referral spreadsheet recording assessment due dates, follow-up review dates and review reasons.

Verbatim wording from the response

“Improved process A new streamlined process has been implemented, where staff add the referrals to a spreadsheet with ‘assessment due date’ documented based on assessment criteria. This new process allows staff to filter the data easily and has improved ways of working. Patients already seen and requiring follow up remain on the spreadsheet with a ‘review date’ documented and reason for review.”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 2 · response
Published 28 June 2021

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

Report missed triage review timeframes through Datix and review incidents weekly at the Incident Review Group.

Verbatim wording from the response

“Incident reporting The Dietetic Service has recognised that it is not always able to meet the target times to review patients that it sets itself due to the increase in demand. Incidents are reported via the Trust’s incident reporting system (Datix), when patients are not reviewed within the timeframe specified at triage. The incidents are reviewed weekly at the Incident Review”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 2 · response
Published 28 June 2021

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

Monitor caseloads regularly to ensure patients are prioritised and seen within appropriate timescales.

Verbatim wording from the response

“• Caseload management monitored regularly to ensure patients are prioritised and seen in a timely manner.”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 2 · response
Published 28 June 2021

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

Combine specialist acute caseloads and prioritise them across the service.

Verbatim wording from the response

“Additional measures implemented by the Dietetic Service to mitigate the risk are as follows:”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 2 · response
Published 28 June 2021

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

Conduct twice-daily senior-dietitian triage and prioritise referrals using referral criteria and clinical judgement.

Verbatim wording from the response

“Twice daily triage There is twice daily triage by a senior dietitian. All referrals for new patients are triaged by the Dietitians and prioritised according to the dietetic referral triaging criteria, ‘The Inpatient ward referral triage criteria’ (Appendix A), details the target times for reviewing referred patients in line with priority category. However, the Dietitians review all referrals in full and use clinical judgement to review a patient sooner if necessary.”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 1 · response
Published 28 June 2021

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

Request a commissioning-led review to assure consistent delivery of service levels.

Verbatim wording from the response

“In addition to the steps taken and in order to support the Trust in the delivery of this service, I have requested a commissioning led review so that I can be assured that service levels can be consistently delivered.”

Source location

2021-0208-Response-from-Stockport-CCG_Published
Page 1 · response
Published 28 June 2021

Open published response

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

Existing out-of-hours guidance is considered sufficient to ensure appropriate nutrition and prevent weekend delays without routine dietetic review.

Verbatim wording from the response

“7 day provision The service is not commissioned to run over 7 days and this is in line with other Greater Manchester NHS Trusts. The target times for reviewing patients are in line with priority categories. However, there is weekend provision currently in place in the form of out of hours guidance, available for all staff, which includes feeding regimes for patients on enteral feeding or parenteral feeding: this supports appropriate nutrition being available over weekends ensuring no delays. A copy is attached in Appendix B and C. The subsequent”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 1 · response
Published 28 June 2021

Open published response

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 dietetic service cannot provide seven-day cover because it is not commissioned to operate seven days.

Verbatim wording from the response

“7 day provision The service is not commissioned to run over 7 days and this is in line with other Greater Manchester NHS Trusts. The target times for reviewing patients are in line with priority categories. However, there is weekend provision currently in place in the form of out of hours guidance, available for all staff, which includes feeding regimes for patients on enteral feeding or parenteral feeding: this supports appropriate nutrition being available over weekends ensuring no delays. A copy is attached in Appendix B and C. The subsequent”

Source location

2021-0208-Response-from-Stepping-Hill-Hospital_Published
Page 1 · response
Published 28 June 2021

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026