Brian Smith

Dear HM Coroner, Name: Brian Smith Date of birth: 11/02/1942 Date of death: 28/11/2025 NHS number: 442 292 0944 Firstly, on behalf of the Trust, I would like to express my sincere condolences to Mr Smith’s family for their loss. We have carefully reviewed the concerns raised in the Regulation 28 Report, specifically in relation to nutritional care and treatment provided to patient’s following their MUST (Malnutrition Universal Screening Tool) score triggering a 3 or above and the requisite utilisation and completion of daily fluid balance and food charts. In the circumstances, we provide the following response: Process Within 24 hours of a patient being admitted to a Ward, the patient will be weighed and scored using the Trust’s MUST policy (copy attached). In the event that the patient cannot be weighed due to being bed bound or no scales on the ward, then a mid-upper arm circumference (MUAC) to secure an indication of the patient’s BMI will be obtained to complete the MUST score in the alternative. The Trust’s policy is consistent with British Association for Parenteral and Enteral Nutrition (BAPEN). If a patient’s MUST score is 3 or more, then a referral will be made to the Trust’s Dietitian Service and daily fluid and food chats will be completed for the patient immediately. I attach a copy of the B1

[Page 2] Trust’s food chart for your reference, which is printed in bright yellow within medical records for easy visibility, and requires sign off by a Registered Nurse. The Trust has a team of nine Dietitians and a Dietitian Assistant. The Dietitian Service respond to all urgent referrals within one working day and routine referrals within three working days. Whilst the ward staff are awaiting the Acute Dietitian to attend the ward, staff will implement the first line advice for patients/Guidance for patients with poor dietary intake. I attach a copy of the document for your reference. Once the Acute Dietitian has attended, a nutrition plan will be compiled and the MUST score calculation will be re-calculated every 7 days and recorded within the Trust’s MUST tool. In the event that a patient is referred to the Dietitian Service but is discharged from the Trust before the Acute Dietitian can complete the referral, the Acute Dietitian will still review the patient’s notes post discharge and determine whether a referral to the Community Dietitian or patient’s GP is required or whether nutrition information can be circulated to the patient at home. On average, the Acute Dietitians receive circa 200-250 referrals per calendar month from the Trust’s wards. The Trust also have Band 6 Nutrition Champions who are appointed to each ward and attend the Nutrition and Hydration Group. Training The Trust is committed to the ongoing training and development of staff to ensure skills, knowledge and competencies remain current. This is demonstrated by promoting a culture of continuous learning and development opportunities. Clinical Induction All clinical induction training at the Trust includes: -
1. Fluids and Nutrition e-learning module, this is an ‘essential to role’ training module for all clinicians (which includes all registered adult nurses, Healthcare Assistants and Allied Health Professionals) and must be completed as part of the Trust’s induction programme. The Fluid and Nutrition e-learning module is British Association for Parental and Enteral Nutrition (BAPEN) compliant and provides training in respect of MUST scoring and completion of fluid balance and food charts. This module is completed online and takes approximately 45 minutes with a test to complete at the end. Time is scheduled within the clinician’s induction week on a Wednesday afternoon to complete this training. The MUST e-learning module results are: Fluid and Nutrition (e-learning) Nov ‘25 Jun ‘26 AMU 87.76% 96.23% B2

[Page 3] Please note that the Trust wide compliance rate is 95% for this essential training module. Finally, the Fluid and Nutrition e-learning module must be completed as a refresher course every three years by all relevant clinicians.
2. Getting Ahead of Harm (GAOH) Training, this is a mandatory training module for all clinical inductions which is held on a Friday on each induction week to all clinicians. The training course was incorporated into clinical induction training circa 18 months ago and includes training in relation to completion of fluid balance and food charts. GAOH is provided face to face by a Band 6 Acute Dietitian and each sessions lasts 45 - 60 minutes. Education In addition to the Trust’s induction programme the Trust also undertakes regular training as follows:
1. Development/Education days: Speech and Language Therapy (SALT) attended the development day in April to feed back to AMU on the AMU accreditation completed on 28 April 2026.
2. Practice Based Educators: Two practice-based educators were recruited to role in November
2025. The Trust’s Practice Based Educators (PBE) are registered Nurses who provide regular face to face in practice training to staff.
a. Ward Rounds: The PBEs attend weekly ward rounds (which includes AMU), to complete ad hoc spot checks on all documentation, including completion and endorsement of food charts. The PBE’s will also speak and educate staff (including Nurses and HCAs) during these ward rounds to educate staff and educate them on the importance to complete in full and endorse food charts for oversight for those patients identified as at a risk of malnutrition.
b. Training Trolley Tuesdays: The Trust’s initiative is led by a PBE and a Unit Manager (UM) weekly. The trolley set up allows the PBE and UM to go from ward to ward to provide training on a specific topic, to quiz staff and to answer any questions staff may have on that topic.
c. Case Studies: the PBEs have developed a case study in respect of the outcome of the Mr Smith’s inquest and the learning identified has been shared across all wards throughout the month of July.
3. Nutrition Link Nurses: The Trust has Nutrition Link Nurse Champions on each ward-whose aim is to provide continuous essential advice in respect of nutrition and hydration to maintain essential aspects of a patient’s care and to support ongoing improvements in practice. The Champions attend a quarterly Nutrition and Hydration Champions Meeting chaired by The Professional Standards Practitioner. In attendance is Matron, Ward Managers, SALT, B3

[Page 4] Dietitian, PBE, HCAs and housekeepers. At the July 2026 meeting, the topic was MUST & Food Chart compliance.
4. Safety Huddles: Ward safety huddles are attended by Matrons, Ward Staff and Housekeeping. Housekeepers deliver all meals for patients therefore they attend all safety huddles on the wards to ensure all patients with additional nutritional requirements are known to everyone and captured within each mealtime. Furthermore, bed side handovers are completed every day and all patients with additional nutritional needs or require assistance with feeding are highlighted so all staff are aware on the ward.
5. Doctors Board/Ward Rounds: these are typically attended by the Consultant or registrar, junior doctors, nursing staff and therapists and are held twice a day. The purpose is to review patients collectively and so that decisions around treatment, rehabilitation and discharge can be made quickly and collaboratively. This will include nutritional needs outstanding actions from MUST assessment and escalations to dietetics and other specialist services.
6. National Nutrition Month of March: The Trust were active participants in the National Nutrition Month. The Trust held a Nutrition and Hydration (N&H) Week, week commencing 16-22 March 2026. the Trust held MUST Monday and fluid balance Tuesday. We attach a copy of the N&H week schedule for your reference. Auditing/Monitoring The Trust undertakes a monthly audit of food and fluid balance charts as part of the Quality Assurance Round (QAR). The QAR provides a framework to self-assess standards, design and develop transformative clinical initiatives to enhance efficiency, improve quantum and build capacity and capability. The monthly audit is completed by the Ward Manager or a senior member of staff. The QAR focuses on engaging staff and empowering leaders to improve standards and quality on clinical areas. This is based on the continuous improvement principle. Item 7 of the QAR relates to nutrition. The result from the QAR enables staff to identify any areas of improvement in the standard of care delivered. Thereafter, any improvements will be implemented by the Ward Manager with the support of the Quality and Patient Experience Team. At the beginning of August, the Assistant Chief Nurse disseminated the findings of the QAR to the Lead Nurses and Matron of each Division expressing encouragement to wards, departments and teams to use QAR to identify improvement work and feed this back to their areas. It has been expressed to Divisional Nurse Directors that the results from the QAR will now be included in their divisional quality updates to the Trusts Patient Safety and Quality Group (PSQG) chaired by the Deputy Chief Nurse. Furthermore, AMU have in post a new Ward Manager as of December 2025 and a PBE. For completeness, the table below presents the combined scores for the five nutrition-related questions across adult inpatient wards for January – June 2026. B4

[Page 5] Question Jan Feb Mar Apr May Jun
10. Has a MUST assessment and any 85% 86% 82% 84% 94% 95% required reassessment been completed accurately and within correct timescales?
23. Are food charts only commenced on 100% 97% 100% 98% 100% 100% patients who require them?
24. Where required have food charts been 95% 94% 98% 89% 95% 97% commenced and fully completed?
25. If there is cause for concern regarding 93% 100% 100% 93% 96% 100% nutritional intake, has this been documented and escalated appropriately?
7. For patients at high risk of malnutrition 88% 94% 94% 88% 100% 100% or who require assistance with eating, the red check tray standards are followed? An accreditation was completed on AMU on 28 April 2026. One of the standards measured is Nutrition and Hydration. AMU scored ‘green’ for Nutrition and Hydration in September 2025 and April
2026. Within the accreditation review undertaken in April 2026 the following questions formed part of the review: - 9: Nutritional assessments are reviewed every 7 days / or 3 days if a Observe records subjective assessment has been undertaken, or sooner if there is a change to the patient e.g. has become NBM 11: Trust food charts are completed appropriately Observe records including, portion size, volume and supplements where appropriate Additionally, Ward Managers and Matrons also complete ad hoc spot check audits of patient’s daily food and fluid balance charts. If there is incomplete or missing documentation the Ward Manager or Matron will hold a 1-1 with individual staff to provide additional support and reinforcement of the importance of completion of these documents. Following the inquest of Mr Smith, the Dietitian Service are undertaking a separate audit in Summer 2026 in respect of MUST scoring and completion of daily fluid/food charts to check accuracy and completion levels. The intention is to randomly select 50 patients on AMU, over a 48 hour period, to ensure MUST scores have been calculated correctly, daily food charts have been completed and B5

[Page 6] appropriate referrals have been made, if required, in line with the Trust’s MUST policy and Guidance for Patients with Poor Dietary Intake. A copy of the aforesaid policy is attached for your reference. Following analysis of the results the Dietitian Service will feed this back to AMU and the Nutrition Committee at the N&H Group by Autumn 2026. Nutrition and Hydration Group The Trust also has a Nutrition and Hydration (N&H) Group, which meets monthly and is chaired by Consultant Gastroenterologist. In attendance at the N&H Group meetings are members of the Trust’s Division, Assistant Chief Nurse, Matrons from each division, Ward Managers, Professional Standards and Patient Experience Practitioners, Speech and Language Therapists (SALT) and Dietitians leads. A quarterly update and assurance report is provided to the Trust Patient Safety Quality Group chaired by the Deputy Chief Nurse. All nutrition and hydration incidents reported across the Trust are monitored via the Trust’s governance processes and reviewed at the N&H Group; the themes of which are fed back to each ward by the Matrons in attendance. Furthermore, the findings from the inquest of the late Mr Brian Smith was shared at N&H Group in July 2026, by the Head of Legal Services, together with the learning identified. Other Nutritional Incentives Several Wards including AMU are equipped with interactive patient safety boards behind each patient’s bed, which displays key subtle indicators in respect of a patient’s personal requirements. For example, if a patient is at risk of malnutrition, then a red tray will be displayed on the patient’s back board. This is a discrete visual alert which highlights to staff immediately that the patient may require assistance, supervision, extra time or specialised meals at mealtimes. Dependent on the Ward, the Trust has menus which include a red dot on certain meals to indicate that these are meals which are the most suitable for patients with additional nutritional needs. On AMU patients receive their meal on a red paper mat to indicate the nutritional status of a patient. The purpose and benefits of patient back boards are to prevent malnutrition and dehydration and to provide reassurance to patient’s and relative that their nutrition and hydrations are being monitored. As of April 2026, the Trust piloted the blue-plate initiative which is a scheme to encourage better nutrition habits in dementia patients, by encouraging them to eat more food, improve nutritional health, make meals more appetising and reduce food waste. This pilot scheme has been led by lead dementia nurse, matron and sustainability. B6

[Page 7] The Trust remains committed to continuous improvement in patient safety and ensuring that learning from this case is embedded in practice. At Tameside and Glossop Integrated Care NHS Foundation Trust, it is our prerogative to ensure that healthcare services are safe, effective, accountable and continuously improving. It is important to us that concerns are reviewed, and learning identified and shared across clinical teams as this helps us to strive to prevent harm and improve outcomes for our patients. I do hope that this letter provides you with further reassurance, however, should you have any queries arising from the content of this letter or require further information or clarification, please do not hesitate to contact Legal Services on