NHS University Hospitals Trust Plymouth
NHS / Health Body
Action Planned
University Hospitals Plymouth NHS Trust will undertake regular audits of nutrition care, provide education on measuring mid-upper arm circumference, and share findings from an investigation across the organization. (AI summary)
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Dear Mr Davies,
I am writing in response to your recently issued Regulation 28 Report dated the 22nd of May 2025 concerning the death of Mr David Bateman. On behalf of University Hospitals Plymouth NHS Trust (UHP), we would like to begin by offering our sincere condolences to Mr Bateman’s family for their loss.
Thank you for highlighting the concerns regarding Mr Bateman’s death, we apologise that you have had to bring these concerns to our attention. We understand the severity of your concerns and are committed to making the necessary improvements that ensures the quality and safety of our services and prevents harm to future patients.
During the course of the inquest the evidence revealed matters giving rise to concern. The matters of concern included the following:
• The finding of poor nursing care and treatment, particularly relating to ineffective support for taking nutrition and insufficient monitoring of weight (during the immediate post-operative period, from the 3rd of September to the 24th of December 2023) that was possibly causative of Dave’s death and the evidence of the treating consultant that such poor care raised a mortality risk for other patients.
• There was no evidence before the court that these concerns have been addressed and remedied.
A full investigation into each of your concerns has been undertaken and I have documented our response below.
The finding of poor nursing care and treatment, particularly relating to ineffective support for taking nutrition and insufficient monitoring of weight (particularly during the immediate post-operative period, from the 3rd of September to the 24th of December 2023) that was possibly causative of Dave’s death and the evidence of the treating consultant that such poor care raised a mortality risk for other patients.
Mr Bateman was admitted to UHP on the 3rd of September 2023 for an elective laparoscopic panproctocolectomy, ileostomy, and omental packing. He was discharged on 23rd of September 2023 to a community hospital for rehabilitation. Mr Bateman experienced complications that resulted in multiple readmissions to UHP, occurring between the 1st of October 2023, and the 14th of March 2024. Initially, he was readmitted due to recurrent pelvic collections requiring surgical intervention and antibiotic therapy. Subsequently, he demonstrated a significant decline in engagement with staff (including the nursing and physiotherapy teams), decreased oral intake leading to weight loss, and reduced mobility.
Mr Bateman was reviewed by the Healthcare of the Elderly and Psychiatry teams in December 2023, who initially considered Mr Bateman as having capacity and attributed his decline to a combination of prolonged hypoactive delirium and depression, and he was treated accordingly with antidepressants. However, during his admission in February 2024, Mr Bateman’s low mood and fluctuating engagement with healthcare staff were considered to potentially be related to underlying or mild dementia, which may have been exacerbated by the primary surgery and post-operative complications.
Optimising Mr Bateman’s nutritional intake during the immediate post-operative period would have been essential in supporting his recovery. The UHP Nutrition & Hydration Policy outlines that a malnutrition risk assessment be performed for all adult inpatients within 24 hours of admission, with follow-up assessments conducted weekly. This assessment should include the completion of the Malnutrition Universal Screening Tool (MUST – Appendix 1), which helps identify patients who are either malnourished at the time of assessment or at risk of developing malnutrition. The results of the risk assessment should guide subsequent care planning, and interventions should be appropriate to the level of risk identified.
A review of Mr Bateman’s clinical records indicates that a MUST was conducted on the 7th of September 2023. At that time, Mr Bateman weighed 86kg, and his MUST score was recorded as 0. He was rescreened on the 17th of September 2023, during which his weight was documented as 81.1 kg, representing a 5.9% decrease in weight. The MUST score at this subsequent assessment was 1, and a three-day food chart was implemented as Mr Bateman was identified as being at medium risk of malnutrition. His nutritional intake was monitored throughout this period, and no further concerns were noted prior to his discharge for ongoing rehabilitation at a community hospital on the 23rd of September 2023.
Mr Bateman was readmitted to UHP on the 1st of October 2023. The investigation could not find evidence indicating that Mr Bateman was weighed or that a MUST was conducted until the 2nd of November 2023, when his weight was recorded as 72.25 kg, representing a 16% weight loss, and his MUST score was documented as 4. There is documentation suggesting that a MUST was considered on the 1st of October, 16th of October, and the 29th of October 2023. However, the screening could not be completed as the nursing team was unable to calculate Mr Bateman’s weight, primarily because Mr Bateman declined to be weighed. It is not clear from the review if the risks associated with
malnutrition and the importance of a weight was explained to Mr Bateman, and it is acknowledged that alternative methods, as outlined in Appendix 1, could have been employed. For example, the team could have considered estimating Mr Bateman’s weight using measurements of mid-upper arm circumference (MUAC).
Once Mr Bateman's weight loss was appreciated, a food chart was implemented and a dietician referral was made on the 2nd of November 2023, and he was reviewed by the team on the 3rd of November 2023. Addition supplements (ensure plus, and fortified milk) were ordered and supplied to Mr Bateman to support with his nutritional intake, and a discussion was had with him regarding the potential for nasogastric tube feeding should his appetite/nutritional intake not improve. Mr Bateman was reviewed again by the dietician on the 7th of November 2023, and Mr Bateman’s nutritional intake remained poor, therefore an increase in supplements was made. Mr Bateman was discharged from the dietician team, and he was discharged from UHP for on the 11th of November 2023.
Mr Bateman was later readmitted on the 25th of November 2023, and a MUST was conducted upon admission. His weight was recorded as 71kg, representing a 17.5% weight loss with a MUST score of
0. A subsequent MUST was performed on the 28th of November 2023, indicating a weight of 71.95 kg and a MUST score of 0. He was referred to and reviewed by a dietitian on the 30th of November 2023, who recommended ongoing monitoring of his nutritional intake supported by supplements which were ordered and provided.
Mr Bateman was reassessed on the 12th of December 2023, and his weight was documented as 67kg, indicating a 22% weight loss, and his MUST score recorded as 4. He was reviewed again by the dietitian on the 14th of December 2023, and a plan was implemented for nasogastric tube placement to facilitate enteral feeding. A nasogastric tube was inserted by the nursing team on the same day, although later inadvertently removed resulting in replacement. Mr Bateman’s weight continued to fluctuate in the subsequent months despite encouragement to eat and drink, and intermittent enteral feeding and his recorded weight on discharge from Wolf ward on the 6th of February 2024 was
71.45kg.
In conclusion, the investigation determined that Mr Bateman's post-operative recovery was protracted and complicated by multiple issues and complications, which significantly affected his mood and mental health, leading to reduced engagement with care. While there is evidence that weight measurements and MUST assessments were conducted at various points during his stay, and that food charts, supplements, and dietician input were considered and utilised, the frequency of weights and reassessment should have been more prompt at times. Additionally, there were missed opportunities to address challenges in completing weight measurements, when Mr Bateman declined and no evidence was found that alternative methods for estimating Mr Bateman’s weight and malnutrition risk were considered when a weight could not be gained. This may have supported the team to have implemented more timely interventions particularly between the 1st of October 2023 and the 2nd of November 2023.
The Trust has reflected on these findings and improvements will be made as outlined in the improvement plan in Appendix 2.
There was no evidence before the court that these concerns have been addressed and remedied.
The Trust acknowledges that there were two missed opportunities to have identified and addressed the concerns raised during the inquests. First whilst Mr Bateman was an inpatient as there were frequent discussions with his family regarding their concerns about his deconditioning, reduced
engagement with care, and poor nutritional intake, and secondly following Mr Bateman’s death when the Service Line undertook a structured judgement review. The Trust apologises that these concerns were not addressed prior to the inquest and hopes that this response provides some reassurance that we have fully explored the concerns raised, and that we are committed to taking the necessary steps to improve the safety of our services.
Should you have any further questions please do not hesitate to contact me. Once again, we extend our deepest condolences to Mr Bateman’s family.
I am writing in response to your recently issued Regulation 28 Report dated the 22nd of May 2025 concerning the death of Mr David Bateman. On behalf of University Hospitals Plymouth NHS Trust (UHP), we would like to begin by offering our sincere condolences to Mr Bateman’s family for their loss.
Thank you for highlighting the concerns regarding Mr Bateman’s death, we apologise that you have had to bring these concerns to our attention. We understand the severity of your concerns and are committed to making the necessary improvements that ensures the quality and safety of our services and prevents harm to future patients.
During the course of the inquest the evidence revealed matters giving rise to concern. The matters of concern included the following:
• The finding of poor nursing care and treatment, particularly relating to ineffective support for taking nutrition and insufficient monitoring of weight (during the immediate post-operative period, from the 3rd of September to the 24th of December 2023) that was possibly causative of Dave’s death and the evidence of the treating consultant that such poor care raised a mortality risk for other patients.
• There was no evidence before the court that these concerns have been addressed and remedied.
A full investigation into each of your concerns has been undertaken and I have documented our response below.
The finding of poor nursing care and treatment, particularly relating to ineffective support for taking nutrition and insufficient monitoring of weight (particularly during the immediate post-operative period, from the 3rd of September to the 24th of December 2023) that was possibly causative of Dave’s death and the evidence of the treating consultant that such poor care raised a mortality risk for other patients.
Mr Bateman was admitted to UHP on the 3rd of September 2023 for an elective laparoscopic panproctocolectomy, ileostomy, and omental packing. He was discharged on 23rd of September 2023 to a community hospital for rehabilitation. Mr Bateman experienced complications that resulted in multiple readmissions to UHP, occurring between the 1st of October 2023, and the 14th of March 2024. Initially, he was readmitted due to recurrent pelvic collections requiring surgical intervention and antibiotic therapy. Subsequently, he demonstrated a significant decline in engagement with staff (including the nursing and physiotherapy teams), decreased oral intake leading to weight loss, and reduced mobility.
Mr Bateman was reviewed by the Healthcare of the Elderly and Psychiatry teams in December 2023, who initially considered Mr Bateman as having capacity and attributed his decline to a combination of prolonged hypoactive delirium and depression, and he was treated accordingly with antidepressants. However, during his admission in February 2024, Mr Bateman’s low mood and fluctuating engagement with healthcare staff were considered to potentially be related to underlying or mild dementia, which may have been exacerbated by the primary surgery and post-operative complications.
Optimising Mr Bateman’s nutritional intake during the immediate post-operative period would have been essential in supporting his recovery. The UHP Nutrition & Hydration Policy outlines that a malnutrition risk assessment be performed for all adult inpatients within 24 hours of admission, with follow-up assessments conducted weekly. This assessment should include the completion of the Malnutrition Universal Screening Tool (MUST – Appendix 1), which helps identify patients who are either malnourished at the time of assessment or at risk of developing malnutrition. The results of the risk assessment should guide subsequent care planning, and interventions should be appropriate to the level of risk identified.
A review of Mr Bateman’s clinical records indicates that a MUST was conducted on the 7th of September 2023. At that time, Mr Bateman weighed 86kg, and his MUST score was recorded as 0. He was rescreened on the 17th of September 2023, during which his weight was documented as 81.1 kg, representing a 5.9% decrease in weight. The MUST score at this subsequent assessment was 1, and a three-day food chart was implemented as Mr Bateman was identified as being at medium risk of malnutrition. His nutritional intake was monitored throughout this period, and no further concerns were noted prior to his discharge for ongoing rehabilitation at a community hospital on the 23rd of September 2023.
Mr Bateman was readmitted to UHP on the 1st of October 2023. The investigation could not find evidence indicating that Mr Bateman was weighed or that a MUST was conducted until the 2nd of November 2023, when his weight was recorded as 72.25 kg, representing a 16% weight loss, and his MUST score was documented as 4. There is documentation suggesting that a MUST was considered on the 1st of October, 16th of October, and the 29th of October 2023. However, the screening could not be completed as the nursing team was unable to calculate Mr Bateman’s weight, primarily because Mr Bateman declined to be weighed. It is not clear from the review if the risks associated with
malnutrition and the importance of a weight was explained to Mr Bateman, and it is acknowledged that alternative methods, as outlined in Appendix 1, could have been employed. For example, the team could have considered estimating Mr Bateman’s weight using measurements of mid-upper arm circumference (MUAC).
Once Mr Bateman's weight loss was appreciated, a food chart was implemented and a dietician referral was made on the 2nd of November 2023, and he was reviewed by the team on the 3rd of November 2023. Addition supplements (ensure plus, and fortified milk) were ordered and supplied to Mr Bateman to support with his nutritional intake, and a discussion was had with him regarding the potential for nasogastric tube feeding should his appetite/nutritional intake not improve. Mr Bateman was reviewed again by the dietician on the 7th of November 2023, and Mr Bateman’s nutritional intake remained poor, therefore an increase in supplements was made. Mr Bateman was discharged from the dietician team, and he was discharged from UHP for on the 11th of November 2023.
Mr Bateman was later readmitted on the 25th of November 2023, and a MUST was conducted upon admission. His weight was recorded as 71kg, representing a 17.5% weight loss with a MUST score of
0. A subsequent MUST was performed on the 28th of November 2023, indicating a weight of 71.95 kg and a MUST score of 0. He was referred to and reviewed by a dietitian on the 30th of November 2023, who recommended ongoing monitoring of his nutritional intake supported by supplements which were ordered and provided.
Mr Bateman was reassessed on the 12th of December 2023, and his weight was documented as 67kg, indicating a 22% weight loss, and his MUST score recorded as 4. He was reviewed again by the dietitian on the 14th of December 2023, and a plan was implemented for nasogastric tube placement to facilitate enteral feeding. A nasogastric tube was inserted by the nursing team on the same day, although later inadvertently removed resulting in replacement. Mr Bateman’s weight continued to fluctuate in the subsequent months despite encouragement to eat and drink, and intermittent enteral feeding and his recorded weight on discharge from Wolf ward on the 6th of February 2024 was
71.45kg.
In conclusion, the investigation determined that Mr Bateman's post-operative recovery was protracted and complicated by multiple issues and complications, which significantly affected his mood and mental health, leading to reduced engagement with care. While there is evidence that weight measurements and MUST assessments were conducted at various points during his stay, and that food charts, supplements, and dietician input were considered and utilised, the frequency of weights and reassessment should have been more prompt at times. Additionally, there were missed opportunities to address challenges in completing weight measurements, when Mr Bateman declined and no evidence was found that alternative methods for estimating Mr Bateman’s weight and malnutrition risk were considered when a weight could not be gained. This may have supported the team to have implemented more timely interventions particularly between the 1st of October 2023 and the 2nd of November 2023.
The Trust has reflected on these findings and improvements will be made as outlined in the improvement plan in Appendix 2.
There was no evidence before the court that these concerns have been addressed and remedied.
The Trust acknowledges that there were two missed opportunities to have identified and addressed the concerns raised during the inquests. First whilst Mr Bateman was an inpatient as there were frequent discussions with his family regarding their concerns about his deconditioning, reduced
engagement with care, and poor nutritional intake, and secondly following Mr Bateman’s death when the Service Line undertook a structured judgement review. The Trust apologises that these concerns were not addressed prior to the inquest and hopes that this response provides some reassurance that we have fully explored the concerns raised, and that we are committed to taking the necessary steps to improve the safety of our services.
Should you have any further questions please do not hesitate to contact me. Once again, we extend our deepest condolences to Mr Bateman’s family.