Jacqueline Marie Antoinette Frehe · Prevention of Future Deaths report

On 2 September 2025, I commenced an investigation into the death of Jacqueline Marie Antoinette Frehe, aged 97 years.

The medical cause of death was:

1a Aspiration pneumonia
1b Frailty of old age
2 Atrial fibrillation

How, when and where Mrs Frehe came by her death:

Mrs Frehe was a frail lady with a history of swallowing difficulties. On 24 August 2025 she was admitted to Yeovil District Hospital with vomiting and a productive cough. It is likely that she had aspirated vomit and secretions which led to pneumonia. On transfer from the emergency department to the ward, Mrs Frehe’s nil by mouth status was not handed over. On the morning of 25 August 2025, she was given food and drink, following which she vomited. Within two hours, Mrs Frehe’s condition deteriorated significantly and she died in hospital that day.

Conclusion

Natural causes to which the aspiration of vomit after eating and drinking made a contribution.

Mrs Frehe was assessed at the Emergency Department of Yeovil District Hospital on 24 August 2025 with dysphagia, vomiting and suspected aspiration pneumonia. The treatment plan was for her to remain nil by mouth, to receive intravenous fluids and antibiotics and to have a speech and language therapy assessment. On transfer to the Acute Medical Unit, her nil by mouth status was not communicated between the ED and the ward by staff. When Mrs Frehe’s family mentioned her nil by mouth status, this was not documented by ward staff. Mrs Frehe was given food and drink on the morning of 25 August 2025 which led to a vomiting episode which likely contributed to her significant deterioration and death within about two hours.

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.