Aneurin Bevan University Health Board
NHS / Health Body
Action Planned
Aneurin Bevan University Health Board has established a governance structure focused on nutrition and hydration and is implementing an action plan including improved recording of patient capacity, review of documentation, and nutrition-focused learning days. (AI summary)
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Dear Ms Saunders
Response to Regulation 28 Report received following the inquest touching on the death of Marina Lorraine Waldron
Thank you for your letter and accompanying report, which the Health Board received on 22 May
2025. I am writing to provide you with the Health Board’s response to the Regulation 28 report to prevent future deaths, following the inquest into the death of Marina Lorraine Waldron. To provide assurance to the Coroner that sustained improvements are being embedded across our organisation, we have established a dedicated governance structure focused on nutrition and hydration.
This structure strengthens our ability to deliver coordinated quality improvement initiatives and ensures systematic oversight through our Quality Management System. The governance model comprises a strategic group supported by two operational sub-groups, each with defined responsibilities and multi-disciplinary representation to ensure robust oversight from board to ward.
The Strategic Nutrition and Hydration Group provides senior leadership and organisational accountability. It is chaired by the Assistant Director for Allied Health Professions and Health Science, with Deputy Director-level representation from Nursing and Medicine. Membership includes colleagues from finance, digital, quality and patient safety, with Llais invited to participate to ensure the voice of service users is reflected. The group meets every two months and has standing agenda items including review of incident trends, risk register monitoring, and oversight of strategic improvement programmes. It also acts as an expert advisory group to the wider organisation on matters relating to nutrition and hydration safety.
Two operational sub-groups report directly to the Strategic Group:
• Food Standards Group – A multi-disciplinary group with responsibility for day-to-day operational oversight of food service delivery and specialist dietary needs. The group reviews incidents, identifies service improvements, and plays a key role in implementing the updated All-Wales Nutrition and Catering Standards for Food and Fluid Provision for Hospital
Inpatients. This group meets monthly and escalates key issues and recommendations to the Strategic Group.
• Clinical Standards Group – A multi-professional group overseeing clinical practice and standards relating to nutrition and hydration across acute, community, maternity, paediatric, and older adult services. This group ensures consistent clinical standards, monitors nutrition- related incidents, oversees risk assessments, and drives delivery of associated action plans. It also meets monthly and reports directly into the Strategic Group.
The introduction of this governance framework has already supported the implementation of key improvement actions at pace, including enhanced monitoring of fluid balance, improved escalation protocols for malnutrition risk, and strengthened documentation and compliance monitoring. These initiatives are being embedded within our Quality Management System and have enabled a more responsive and accountable approach to preventing avoidable harm.
In summary, this strengthened governance structure ensures senior oversight, operational alignment, and service user involvement in driving continuous improvement in nutrition and hydration safety. It provides a clear mechanism for ensuring that learning from serious incidents translates into meaningful and sustainable change across the organisation.
As requested, the information presented below outlines the actions that have been taken and are being taken by Aneurin Bevan University Health Board to mitigate the risk of similar incidents occurring in future. These actions are framed within a comprehensive, multi-professional, timed improvement programme which is included as an appendix to this letter.
Concern 1: Failure to heed the family’s concerns about poor nutritional intake
We acknowledge the family's repeated concerns and regret that these were not adequately responded to. To address this, the Health Board has implemented or will implement actions under Recommendation 1 of the attached plan, including:
• Introduction of ward-level reflection sessions using anonymised case studies to explore communication challenges.
• Piloting of the divisional communication tool, AIDET and “difficult conversations” training.
• Promotion of the “Call for Concern” protocol to enable families to escalate issues directly.
• Inclusion of Llais (the patient voice) within the Nutrition & Hydration strategic group
Concern 2: Failure to formally monitor dietary intake
To improve compliance and accuracy in monitoring nutritional intake, Recommendation 2 of the action plan focuses on:
• Development and deployment of a “Gold Standard” food chart and supporting 7-minute staff briefing.
• Reinforcement of red tray and visual identifiers for patients requiring dietary monitoring.
• Use of Audit Management and Tracking system (AMaT) data to assess and improve ward- level compliance with food chart use.
• Exploration of environmental barriers such as early tray clearance or single-room isolation.
Concern 3: Failure to respond to low albumin levels
Under Recommendation 3, we are strengthening escalation frameworks to support timely clinical decision-making. Key actions include:
• Dissemination of a Clinical Escalation Framework across all clinical divisions.
• Initiating a thematic review of delayed escalations related to nutritional concerns.
• Incorporation of learning into multidisciplinary forums such as Patent Safety & Quality Learning & Improvement forum
Concern 4: Delayed dietary advice and parenteral feeding consideration
The need for earlier specialist involvement and clear documentation around nutritional care is being addressed through Recommendation 4, including:
• Improved recording of patient capacity and preferences in feeding decisions.
• Review of SBAR (document designed to ensure accurate patient information is recorded and passed to receiving clinician following patient moves) and transfer documentation to include specific prompts on nutrition
• Reassessment of patient transport and discharge processes to ensure nutritional needs are considered.
To embed sustained improvement and shared learning across the organisation, Recommendation 5 focuses on:
• Nutrition & Hydration-focused divisional learning days.
• Presentations of Nutrition & Hydration quality improvement initiatives at key governance forums.
• Integration of progress updates into Quality Safety Learning and Improvement structures.
Ongoing Monitoring and Governance
This action plan has been jointly developed by senior nursing, medical and allied health professions leadership with oversight from the Executive Director of Allied Health Professions (AHP) & Health Science and Executive Director of Nursing. A full governance route is in place, including the Nutrition & Hydration strategic group, Clinical Nutrition & Hydration sub-group, Ward Accreditation processes, and integration into the Health Board’s risk register and quality reporting structures.
I would like to personally assure you that there is organisational-wide commitment to ensuring that the circumstances surrounding Mrs Waldron’s death led to meaningful and lasting improvements in the care of vulnerable patients. Please find enclosed our detailed action plan for your review. Should any further clarification or assurance be required, we would be happy to provide it.
Response to Regulation 28 Report received following the inquest touching on the death of Marina Lorraine Waldron
Thank you for your letter and accompanying report, which the Health Board received on 22 May
2025. I am writing to provide you with the Health Board’s response to the Regulation 28 report to prevent future deaths, following the inquest into the death of Marina Lorraine Waldron. To provide assurance to the Coroner that sustained improvements are being embedded across our organisation, we have established a dedicated governance structure focused on nutrition and hydration.
This structure strengthens our ability to deliver coordinated quality improvement initiatives and ensures systematic oversight through our Quality Management System. The governance model comprises a strategic group supported by two operational sub-groups, each with defined responsibilities and multi-disciplinary representation to ensure robust oversight from board to ward.
The Strategic Nutrition and Hydration Group provides senior leadership and organisational accountability. It is chaired by the Assistant Director for Allied Health Professions and Health Science, with Deputy Director-level representation from Nursing and Medicine. Membership includes colleagues from finance, digital, quality and patient safety, with Llais invited to participate to ensure the voice of service users is reflected. The group meets every two months and has standing agenda items including review of incident trends, risk register monitoring, and oversight of strategic improvement programmes. It also acts as an expert advisory group to the wider organisation on matters relating to nutrition and hydration safety.
Two operational sub-groups report directly to the Strategic Group:
• Food Standards Group – A multi-disciplinary group with responsibility for day-to-day operational oversight of food service delivery and specialist dietary needs. The group reviews incidents, identifies service improvements, and plays a key role in implementing the updated All-Wales Nutrition and Catering Standards for Food and Fluid Provision for Hospital
Inpatients. This group meets monthly and escalates key issues and recommendations to the Strategic Group.
• Clinical Standards Group – A multi-professional group overseeing clinical practice and standards relating to nutrition and hydration across acute, community, maternity, paediatric, and older adult services. This group ensures consistent clinical standards, monitors nutrition- related incidents, oversees risk assessments, and drives delivery of associated action plans. It also meets monthly and reports directly into the Strategic Group.
The introduction of this governance framework has already supported the implementation of key improvement actions at pace, including enhanced monitoring of fluid balance, improved escalation protocols for malnutrition risk, and strengthened documentation and compliance monitoring. These initiatives are being embedded within our Quality Management System and have enabled a more responsive and accountable approach to preventing avoidable harm.
In summary, this strengthened governance structure ensures senior oversight, operational alignment, and service user involvement in driving continuous improvement in nutrition and hydration safety. It provides a clear mechanism for ensuring that learning from serious incidents translates into meaningful and sustainable change across the organisation.
As requested, the information presented below outlines the actions that have been taken and are being taken by Aneurin Bevan University Health Board to mitigate the risk of similar incidents occurring in future. These actions are framed within a comprehensive, multi-professional, timed improvement programme which is included as an appendix to this letter.
Concern 1: Failure to heed the family’s concerns about poor nutritional intake
We acknowledge the family's repeated concerns and regret that these were not adequately responded to. To address this, the Health Board has implemented or will implement actions under Recommendation 1 of the attached plan, including:
• Introduction of ward-level reflection sessions using anonymised case studies to explore communication challenges.
• Piloting of the divisional communication tool, AIDET and “difficult conversations” training.
• Promotion of the “Call for Concern” protocol to enable families to escalate issues directly.
• Inclusion of Llais (the patient voice) within the Nutrition & Hydration strategic group
Concern 2: Failure to formally monitor dietary intake
To improve compliance and accuracy in monitoring nutritional intake, Recommendation 2 of the action plan focuses on:
• Development and deployment of a “Gold Standard” food chart and supporting 7-minute staff briefing.
• Reinforcement of red tray and visual identifiers for patients requiring dietary monitoring.
• Use of Audit Management and Tracking system (AMaT) data to assess and improve ward- level compliance with food chart use.
• Exploration of environmental barriers such as early tray clearance or single-room isolation.
Concern 3: Failure to respond to low albumin levels
Under Recommendation 3, we are strengthening escalation frameworks to support timely clinical decision-making. Key actions include:
• Dissemination of a Clinical Escalation Framework across all clinical divisions.
• Initiating a thematic review of delayed escalations related to nutritional concerns.
• Incorporation of learning into multidisciplinary forums such as Patent Safety & Quality Learning & Improvement forum
Concern 4: Delayed dietary advice and parenteral feeding consideration
The need for earlier specialist involvement and clear documentation around nutritional care is being addressed through Recommendation 4, including:
• Improved recording of patient capacity and preferences in feeding decisions.
• Review of SBAR (document designed to ensure accurate patient information is recorded and passed to receiving clinician following patient moves) and transfer documentation to include specific prompts on nutrition
• Reassessment of patient transport and discharge processes to ensure nutritional needs are considered.
To embed sustained improvement and shared learning across the organisation, Recommendation 5 focuses on:
• Nutrition & Hydration-focused divisional learning days.
• Presentations of Nutrition & Hydration quality improvement initiatives at key governance forums.
• Integration of progress updates into Quality Safety Learning and Improvement structures.
Ongoing Monitoring and Governance
This action plan has been jointly developed by senior nursing, medical and allied health professions leadership with oversight from the Executive Director of Allied Health Professions (AHP) & Health Science and Executive Director of Nursing. A full governance route is in place, including the Nutrition & Hydration strategic group, Clinical Nutrition & Hydration sub-group, Ward Accreditation processes, and integration into the Health Board’s risk register and quality reporting structures.
I would like to personally assure you that there is organisational-wide commitment to ensuring that the circumstances surrounding Mrs Waldron’s death led to meaningful and lasting improvements in the care of vulnerable patients. Please find enclosed our detailed action plan for your review. Should any further clarification or assurance be required, we would be happy to provide it.