PFD report

LESLEY MAWBY · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 18 Jun 2021•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
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

Source document

Full report text

This is the full text from the original published report.

Open published report

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
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 recipient says it has done, is doing, or plans to do in response to a concern raised.12

  1. Action

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

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 June 2021.
  2. Action

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

    Stated by Stockport NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 June 2021.
  3. Action

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

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 June 2021.

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

  1. Position

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

    Stated by Stockport NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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.

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

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

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

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

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

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 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

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. 1

    Arrange training for substantive staff to address identified skill gaps.

    Stated by Stockport NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 June 2021.
  2. 2

    Review ward care plans and referral criteria.

    Stated by Stockport NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 June 2021.
  3. 3

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

    Stated by Stockport NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 June 2021.
  4. 4

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

    Stated by Stockport NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 June 2021.
  5. 5

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

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 June 2021.
  6. 6

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

    Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 28 June 2021.

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

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

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

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

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
Back to top

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