Elaine Griffiths

Dear Mr Shah Regulation 28: Report to prevent future deaths re Mrs Elaine Jean Griffiths I write in response to the above report issued on 17th December 2025. I would like to firstly express my sincere condolences to the family of the late Mrs Griffiths and to acknowledge and apologise for the issues related to failures across our nutrition and hydration pathway whilst she was in our care at Northampton General Hospital (NGH). This response to the Regulation 28 Report is to update you on the actions being taken to address the concerns raised. The following improvement plans and actions have been put in place (or are in the process of being embedded across NGH): Evidence at inquest described that at times, fluid and diet charts were partially completed Since June 2025, the fluid balance charts are available on Nervecentre (NC), which is an electronic patient record (EPR). This has improved oversight of our patient documentation and enhanced accessibility for consulting teams. Fluid consumption is now electronically calculated and inputted, so that consulting teams can easily access the correct quantities. As part of our ongoing audit process, staff complete the malnutrition universal screening tool (MUST) and compliance with this is audited by our nutrition nurses. This also encompasses reviewing the accurate completion of the patient food and fluid balance charts as well as assessing whether appropriate actions have been followed based on the patient’s MUST score. A key finding from these audits is that the transferring of the fluid balance charts to NC has resulted in an improvement in timely and accurate completion of the MUST scores. In 2025 our teams updated the Food and Fluid Charts used at NGH and plan to implement these at both NGH and Kettering General Hospital (KGH), the two acute hospitals within University Hospitals of Northamptonshire NHS Group. The improvements include the addition of prompts to indicate:

Kettering General Hospital NHS Foundation Trust Rothwell Road Kettering Northants NN16 8UZ Northampton General Hospital Cliftonville Northampton NN1 5BD

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• When a fluid balance chart should commence;
• When food and drink is brought in by visitors;
• The improved recording of fluid intake following the prescription of oral nutritional supplements.

MUST audit results are detailed below. These scores demonstrate a significant improvement in completion rates of the fluid balance charts since the introduction of the electronic tool, NC.

We are ensuring that our team of Dietitians and Nutrition Nurses continue to work collaboratively in order to develop and deliver monthly training sessions as part of the ongoing Clinical Skills Nursing Programme. These evaluated sessions, in place since January 2026, provide education on essential nutrition and hydration principles, including correct completion of documentation such as the food and fluid balance charts. In addition to this, the Trust appointed a Specialist Catering Dietitian in March 2025, and as part of their remit, they also deliver training for health care assistants and catering staff on nutrition and hydration standards. Addressing the confusion as to whether or not Mrs Griffiths was gluten and dairy intolerant.

It had been documented by a Mental Health Nurse on 31 August 2022 that Mrs Griffiths followed a gluten and dairy free diet and noted that the ward gave her only lentil casseroles. This conflicted with the Consultant Ortho-geriatrician’s notes, who documented that Mrs Griffiths had very poor oral intake and her family were advising that she had an allergy to gluten and lactose, despite Mrs Griffiths denying this.

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Following the implementation of NC at NGH, we have streamlined processes which has led to the improved the recording of this data. This will make the recognition of allergies and intolerances easier to identify and more readily available throughout a patient’s care pathway and for future admissions. To provide you with further assurance, this detail is presented and discussed during ‘Board Rounds’ and therefore also communicated more widely to colleagues involved in a patients care. In order to support with improvement in nutrition and fluid management across the Trust, we are exploring the possibility of all ward level staff involved in food distribution, to attain the food safety level one training module. We are currently in the process of reviewing capacity and resource and hope to start this process in April 2026. The aim will be to roll this approach out across both hospitals. Mrs Griffiths’ family advised that the choice of options for those with gluten and dairy intolerance and for those who require bite sized food was very limited, which disproportionately affects the elderly cohort of patients. In order to meet the National Standards for healthcare food and drink, the Trust appointed a Food Services Dietitian in March 2025. Since taking up post, the Dietitian has completed a comprehensive analysis of the existing texture of the modified menu to assess nutritional adequacy, allergen safety and alignment with patient needs. Following these reviews, we have established a Multidisciplinary Menu Planning Group which has brought together catering, dietetics, nursing and patient representatives in order to improve the food menu design and to ensure a consistent and inclusive availability of suitable options, including those patients with complex dietary requirements. The Trust is also progressing with the procurement of a new meal provider that will offer a more comprehensive range of allergen free meals. We anticipate the full service to be in place by mid- 2026 and in the interim period we are implementing measures to strengthen allergy safe options for patients. These measures have included the introduction of a dedicated snack menu that caters for patients with both swallowing difficulties and food allergies, as well as an increased range of suitable dessert options. Menus will also be updated to ensure coding for allergens is clearer. Mrs Griffiths’ family advised that the fluid and diet charts were not accurate as they had brought in food that was not being recorded in the records. As the charts were inaccurate, this would also have made it more difficult for the dietician to offer meaningful advice. In addition to the information provided above, the Trust has now developed an improvement plan (action plan attached) with respect to the Food and Fluid Charts. These include prompts for staff to document any food or drink brought in by family/visitors. With the planned improvements to the texture modified menu, as well as enhancements across all other menus, our aim is to reduce the requirement for family/visitors to bring in food. Our Dietitians are working to ensure that clinical documentation in relation to food and fluid are completed accurately and in a timely manner, and this requirement will be included as part of the Nutrition Nurses and Practice Development team training. Additionally, they have implemented monthly Clinical Skills training and from March 2026, there are plans for quarterly MUST training sessions.

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I trust that the above information provides assurance on how we have acted on the concerns raised within the Regulation 28 Report and our ongoing work to improve the standard of record keeping and nutrition and fluid provision for our patients. We will write further to Mr Griffiths’ family to apologise and to share details of our learning actions.