Frimley Health NHS Foundation Trust
NHS / Health Body
Action Planned
The Trust has established a new Nutrition and Hydration Safety Steering Group, revised malnutrition and hydration policies, and is launching a new e-learning package for staff. A formal process will be agreed to ensure improved oversight of Harm Free Care audit results and a ward league table will be produced monthly by the Quality Team. (AI summary)
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Dear Mr Simpson REF: YOUR REGULATION 28 REPORT TO PREVENT FUTURE DEATHS (PFD) DATED 27 NOVEMBER 2025 I write further and in response to the Regulation 28 Report received on 27th November 2025, following the sad death of June Violet Findlay on 11th December 2024. My deepest sympathies go out to Mrs Findlay’s family and those who knew her. I am grateful for your thorough inquest into Mrs Findlay’s death. I would like to take this opportunity to reassure you that patient safety is taken very seriously by the Trust, and the Trust is committed to review and reflect on current practices to identify areas of improvement. I have carefully considered your observations, and the recommendations raised in your Regulation 28 Report to ensure that patients receive the best quality care at the Trust and that future deaths are prevented. Summary of Coroner’s Concerns The concerns identified relate to:
1. Recognition of malnutrition risk despite MUST assessments.
2. Inconsistent use of care planning tools.
3. Inadequate monitoring and recording of nutritional interventions.
4. Auditing processes failing to identify repeated documentation gaps. The Trust recognises the serious nature of this PFD and is committed to the improvement work. This will be led by the Deputy Chief Nurse who will report to the Chief of Nursing and Midwifery. A new Nutrition and Hydration Safety Steering Group (NHSSG) will be accountable for the delivery of the actions on the detailed action plan with specific timeframes and owners of actions.
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Actions Taken and Planned Leadership and Accountability:
1. The concerns raised in this PFD report have been shared and discussed with the Chief Executive and all the Executive Directors of the Board.
2. The Trust recognises the importance of nutrition and hydration, and it is a quality priority for the Trust.
3. The response to the PFD and the detailed Trust wide Nutrition and Hydration Improvement Action Plan is being monitored by the new NHSSG and the Quality Assurance Committee, which is a formal Sub Committee of the Trust Board. The NHSSF is a new group which will be attended by Senior Nurses, Dieticians and representatives from the Multidisciplinary Team (MDT) across the organisation. They will be monthly. The action plan will have timescales and owners for every action required which will be closely monitored by this group.
4. Divisional Directors of Nursing (DDONS) within the new Divisional Structure will be required to provide assurance to the Chief of Nursing and Midwifery that the nutrition and hydration needs of patients cared for in their division are being assessed and consistently met and accurately recorded. Nutritional and Hydration Safety Steering Group:
1. A new Nutritional and Hydration Safety Steering Group (NHSSG) was established on the 29.01.26. This is chaired by a Deputy Chief Nurse. The Key Performance Indicators (KPI's) related to nutrition and hydration will be monitored at this meeting. The NHSSG will have the authority to commission specific quality improvement groups as required.
2. All clinical areas including ward, Emergency Department and other outpatient areas to have nutrition link nurses identified who will support the implementation of best practice in clinical areas. They will have a clearly defined role with the nurses completing an education programme.
3. A thorough review/map of all the education programmes/study days that are provided for both registered nurses and healthcare support workers is underway. The aim is to ensure that the training we are providing all staff is fit for purpose. The new education programme will address the following key concerns: documentation to ensure accurate recording of food consumption, protected mealtimes, tray colours and ensuring the patient receives the correct diet for example soft, and when supplements should be given. All staff will be given the updated training and compliance for each clinical area will be monitored by the NHSSG.
4. Protected Mealtimes champions to be identified for each ward. The role of these champions is to ensure that patients are not disturbed or distracted during mealtimes. For example, mealtimes are not disturbed by visits to patients from the multidisciplinary team. Eating their meal is prioritised. Specific training will be provided to enable them to support and monitor the Standard Operating Process that is in place.
5. Review of how Food & Fluid intake can be documented on Epic (Trust Electronic Patient Record) - the daily care flowsheets have been amended to allow for nutritional intake to be documented in more detail. Safety message and electronic patient record (EPR) bulletins have gone out to clinical staff.
6. During February and March, the Clinical Education team and Dietitians will launch the new Education Roadshows to raise awareness and support the clinical teams on the wards.
3
7. The Trust Food and Drink Strategy for 2026 to 2030 will be launched in March 26 by the Trust Facilities Team. All NHS organisations should maintain a food and drink strategy viewed as a living document. It captures how the organisation addresses safe delivery of nutritious and quality food and drink for patients; how healthier food and the right environment for staff and visitors are provided; and embeds sustainable practices in its service, such as buying food more sustainably and wasting less. Outcomes should be detailed and measured, allowing the organisation to demonstrate how it is meeting required standards. This strategy is the blueprint for how the organisation values food and drink as medicine; it will form part of the annual returns required by NHS organisations to evidence compliance with the Food and Drink Standards. New initiative for the Trust to Focus on weight loss.
1. Implement a new system to flag patients with a concerning weight loss which triggers a swarm huddle. A swarm huddle is designed to start as soon as possible after a patient safety incident occurs so in this case significant weight loss is identified. The purpose of the swarm-based huddle is to identify learning from patient safety incidents; this is in line with the National Patients Safety Framework (PSIRF). Immediately after an incident is identified the multidisciplinary staff ‘swarm’ to the ward to quickly analyse what happened and how it happened and decide what needs to be done to reduce risk. Swarms enable insights and reflections to be quickly sought and generate prompt learning. It will be expected that the swarm is attended by the Ward Matron and a member of the Patient Safety Team. The swarm huddle will then formulate an individualised care plan for the patient which will be monitored for compliance by the Ward Manager and Ward Matron. The implementation of this action will be a priority for the NHSSG and implemented within the next 3 months.
2. Develop a Standard Operating Procedure (SOP) for the identification, management and escalation of weight loss.
3. All patients who are identified with significant weight loss in line with the SOP will be escalated to the Ward Matron who will ensure that a full swarm review including dieticians is undertaken and appropriate actions are taken and clearly documented. Ongoing work streams Harm Free Care - A trust campaign was launched in July 2025 to support a focus on 4 key areas relating to improving patient safety. This included improving nutritional care for patients to ensure they are assessed for nutritional status and risk of malnutrition using the malnutrition universal screening tool (MUST). If they are malnourished or at risk, interventions will be implemented to ensure that their status is improved as much as possible. The Harm Free Care launch offered an opportunity to provide refresher training to all clinical staff. Over a period of 3 months bite size training sessions were commenced which included demonstrations on how to complete risk assessments and initiate appropriate care planning on Epic. All Registered Nurses can access the training via micro soft teams, and this will be monitored by the Ward Managers and compliance reported at the NHSSG. The clinical education, Epic training and quality teams visited all wards to offer training and support. A trust wide communication plan was also implemented to raise awareness of the Harm Free Care Programme.
4
There was a refresh of Protected Mealtimes as part of the Harm Free Care Programme launch. Training has commenced to refresh ward hosts awareness and responsibilities in relation to the colour tray system to ensure patients on a red or yellow tray do not have these removed until a registered nurse/healthcare support worker has documented intake. Audit – There will an altered focus on the audit to provide assurance that patients are adequately fed according to their need and that any significant weight loss is appropriately escalated to the Ward Matron to ensure that high risk patients are highlighted and appropriate action is taken and documented in line with the new weight loss SOP. Update the audit programme in July 2025 to the 'Harm Free Care' audit programme this is an ongoing audit. There is now a specific question in the audit that relates to food charts being completed over the last 24 hours. The audit is completed once a month in all adult inpatient areas. The aim is monitoring the effectiveness of the education programme and changes to Epic and the way food intake is recorded. The numbers of patients audited between July 25, and November 25 is 1,528. A monthly observational audit of protected mealtimes was also launched in July 2025 to further support the implementation of the trust Protected Mealtimes (including coloured tray guidelines). A training programme on 'how' to audit' with a guideline was also produced to aid improved data quality. The audit looks at how effective the protected mealtime is on the ward for example are the patients ready to receive their meal having completed their hand hygiene and are they assisted if this is required. Matrons and Senior Sisters are required to conduct the audits. Audit results for Harm Free Care is now presented at ward sisters, matrons, heads of nursing meetings and the NHSSG. The results are also published on the Trust intranet for each individual ward area. Further Action A formal process will be agreed and demonstrated in a standard operating procedure to ensure improved oversight of Harm Free Care audit results. This is to ensure that the audit results are seen by the Divisional Leadership Teams and are then discussed at the appropriate forums with improvements and interventions agreed and monitored within the Divisions. A ward league table will be produced monthly by the Quality Team showing the audit results. These will be sent to the Divisional Director of Nursing to address any concerns I hope that my response highlights the steps that the Trust has and will continue to take to improve the patient safety and in particular nutrition at the Trust. An improvement plan based on learning from this inquest, to include the actions above, will be created and actioned with monitoring by the appropriate clinical governance teams within the Trust. The Trust appreciates your thorough investigation and challenge, both of which are essential so that the Trust can continue to learn lessons and take steps to improve patient safety and the quality of care we provide our patients. As ever, my thoughts remain with Mrs Findlay family and all those affected by her very sad death.
1. Recognition of malnutrition risk despite MUST assessments.
2. Inconsistent use of care planning tools.
3. Inadequate monitoring and recording of nutritional interventions.
4. Auditing processes failing to identify repeated documentation gaps. The Trust recognises the serious nature of this PFD and is committed to the improvement work. This will be led by the Deputy Chief Nurse who will report to the Chief of Nursing and Midwifery. A new Nutrition and Hydration Safety Steering Group (NHSSG) will be accountable for the delivery of the actions on the detailed action plan with specific timeframes and owners of actions.
2
Actions Taken and Planned Leadership and Accountability:
1. The concerns raised in this PFD report have been shared and discussed with the Chief Executive and all the Executive Directors of the Board.
2. The Trust recognises the importance of nutrition and hydration, and it is a quality priority for the Trust.
3. The response to the PFD and the detailed Trust wide Nutrition and Hydration Improvement Action Plan is being monitored by the new NHSSG and the Quality Assurance Committee, which is a formal Sub Committee of the Trust Board. The NHSSF is a new group which will be attended by Senior Nurses, Dieticians and representatives from the Multidisciplinary Team (MDT) across the organisation. They will be monthly. The action plan will have timescales and owners for every action required which will be closely monitored by this group.
4. Divisional Directors of Nursing (DDONS) within the new Divisional Structure will be required to provide assurance to the Chief of Nursing and Midwifery that the nutrition and hydration needs of patients cared for in their division are being assessed and consistently met and accurately recorded. Nutritional and Hydration Safety Steering Group:
1. A new Nutritional and Hydration Safety Steering Group (NHSSG) was established on the 29.01.26. This is chaired by a Deputy Chief Nurse. The Key Performance Indicators (KPI's) related to nutrition and hydration will be monitored at this meeting. The NHSSG will have the authority to commission specific quality improvement groups as required.
2. All clinical areas including ward, Emergency Department and other outpatient areas to have nutrition link nurses identified who will support the implementation of best practice in clinical areas. They will have a clearly defined role with the nurses completing an education programme.
3. A thorough review/map of all the education programmes/study days that are provided for both registered nurses and healthcare support workers is underway. The aim is to ensure that the training we are providing all staff is fit for purpose. The new education programme will address the following key concerns: documentation to ensure accurate recording of food consumption, protected mealtimes, tray colours and ensuring the patient receives the correct diet for example soft, and when supplements should be given. All staff will be given the updated training and compliance for each clinical area will be monitored by the NHSSG.
4. Protected Mealtimes champions to be identified for each ward. The role of these champions is to ensure that patients are not disturbed or distracted during mealtimes. For example, mealtimes are not disturbed by visits to patients from the multidisciplinary team. Eating their meal is prioritised. Specific training will be provided to enable them to support and monitor the Standard Operating Process that is in place.
5. Review of how Food & Fluid intake can be documented on Epic (Trust Electronic Patient Record) - the daily care flowsheets have been amended to allow for nutritional intake to be documented in more detail. Safety message and electronic patient record (EPR) bulletins have gone out to clinical staff.
6. During February and March, the Clinical Education team and Dietitians will launch the new Education Roadshows to raise awareness and support the clinical teams on the wards.
3
7. The Trust Food and Drink Strategy for 2026 to 2030 will be launched in March 26 by the Trust Facilities Team. All NHS organisations should maintain a food and drink strategy viewed as a living document. It captures how the organisation addresses safe delivery of nutritious and quality food and drink for patients; how healthier food and the right environment for staff and visitors are provided; and embeds sustainable practices in its service, such as buying food more sustainably and wasting less. Outcomes should be detailed and measured, allowing the organisation to demonstrate how it is meeting required standards. This strategy is the blueprint for how the organisation values food and drink as medicine; it will form part of the annual returns required by NHS organisations to evidence compliance with the Food and Drink Standards. New initiative for the Trust to Focus on weight loss.
1. Implement a new system to flag patients with a concerning weight loss which triggers a swarm huddle. A swarm huddle is designed to start as soon as possible after a patient safety incident occurs so in this case significant weight loss is identified. The purpose of the swarm-based huddle is to identify learning from patient safety incidents; this is in line with the National Patients Safety Framework (PSIRF). Immediately after an incident is identified the multidisciplinary staff ‘swarm’ to the ward to quickly analyse what happened and how it happened and decide what needs to be done to reduce risk. Swarms enable insights and reflections to be quickly sought and generate prompt learning. It will be expected that the swarm is attended by the Ward Matron and a member of the Patient Safety Team. The swarm huddle will then formulate an individualised care plan for the patient which will be monitored for compliance by the Ward Manager and Ward Matron. The implementation of this action will be a priority for the NHSSG and implemented within the next 3 months.
2. Develop a Standard Operating Procedure (SOP) for the identification, management and escalation of weight loss.
3. All patients who are identified with significant weight loss in line with the SOP will be escalated to the Ward Matron who will ensure that a full swarm review including dieticians is undertaken and appropriate actions are taken and clearly documented. Ongoing work streams Harm Free Care - A trust campaign was launched in July 2025 to support a focus on 4 key areas relating to improving patient safety. This included improving nutritional care for patients to ensure they are assessed for nutritional status and risk of malnutrition using the malnutrition universal screening tool (MUST). If they are malnourished or at risk, interventions will be implemented to ensure that their status is improved as much as possible. The Harm Free Care launch offered an opportunity to provide refresher training to all clinical staff. Over a period of 3 months bite size training sessions were commenced which included demonstrations on how to complete risk assessments and initiate appropriate care planning on Epic. All Registered Nurses can access the training via micro soft teams, and this will be monitored by the Ward Managers and compliance reported at the NHSSG. The clinical education, Epic training and quality teams visited all wards to offer training and support. A trust wide communication plan was also implemented to raise awareness of the Harm Free Care Programme.
4
There was a refresh of Protected Mealtimes as part of the Harm Free Care Programme launch. Training has commenced to refresh ward hosts awareness and responsibilities in relation to the colour tray system to ensure patients on a red or yellow tray do not have these removed until a registered nurse/healthcare support worker has documented intake. Audit – There will an altered focus on the audit to provide assurance that patients are adequately fed according to their need and that any significant weight loss is appropriately escalated to the Ward Matron to ensure that high risk patients are highlighted and appropriate action is taken and documented in line with the new weight loss SOP. Update the audit programme in July 2025 to the 'Harm Free Care' audit programme this is an ongoing audit. There is now a specific question in the audit that relates to food charts being completed over the last 24 hours. The audit is completed once a month in all adult inpatient areas. The aim is monitoring the effectiveness of the education programme and changes to Epic and the way food intake is recorded. The numbers of patients audited between July 25, and November 25 is 1,528. A monthly observational audit of protected mealtimes was also launched in July 2025 to further support the implementation of the trust Protected Mealtimes (including coloured tray guidelines). A training programme on 'how' to audit' with a guideline was also produced to aid improved data quality. The audit looks at how effective the protected mealtime is on the ward for example are the patients ready to receive their meal having completed their hand hygiene and are they assisted if this is required. Matrons and Senior Sisters are required to conduct the audits. Audit results for Harm Free Care is now presented at ward sisters, matrons, heads of nursing meetings and the NHSSG. The results are also published on the Trust intranet for each individual ward area. Further Action A formal process will be agreed and demonstrated in a standard operating procedure to ensure improved oversight of Harm Free Care audit results. This is to ensure that the audit results are seen by the Divisional Leadership Teams and are then discussed at the appropriate forums with improvements and interventions agreed and monitored within the Divisions. A ward league table will be produced monthly by the Quality Team showing the audit results. These will be sent to the Divisional Director of Nursing to address any concerns I hope that my response highlights the steps that the Trust has and will continue to take to improve the patient safety and in particular nutrition at the Trust. An improvement plan based on learning from this inquest, to include the actions above, will be created and actioned with monitoring by the appropriate clinical governance teams within the Trust. The Trust appreciates your thorough investigation and challenge, both of which are essential so that the Trust can continue to learn lessons and take steps to improve patient safety and the quality of care we provide our patients. As ever, my thoughts remain with Mrs Findlay family and all those affected by her very sad death.