Themes | Social Care | The Accountability Index

Care home nutritional choice

Over-reliance on ready meals and insufficient provision of fresh food, limiting personalised meal choices for residents in care settings.

154 items 10 sources 2 inquiries
Source spread

Where this theme appears

This theme appears across 10 independent accountability sources, so the source mix matters as much as the headline total.

2 inquiry recs 5 PFD reports 1 committee rec 43 CQC actions 1 PPO rec 51 IMB recs 5 IMB reports 4 detention investigation recs 27 PHSO decisions 15 LGO/SPSO decisions

Browse by source

Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.

10 sources
Inquiry recommendations(2)
Prevention of Future Deaths reports(5)
Sheila Graham
16 Nov 2018 · Stoke-on-Trent & North Staffordshire
Concerns: Prolonged social isolation for a patient with C. difficile negatively impacted her well-being, compounded by inadequate nutritional information recording and assessment.
Overdue
Louise Cooper
21 Dec 2021 · Blackpool & Fylde
Concerns: The healthcare system lacks sufficient provision for sustained supported eating for anorexia nervosa patients, leading to ineffective hospital admissions and hindering patient improvement despite clinical recommendations.
Overdue
John Fallon
04 Nov 2022 · Manchester South
Concerns: Care homes lack routine speech and language therapy assessments for denture changes, leading to unsuitable diets and increased choking risk due to delayed dental services. Furthermore, care homes do not routinely have suction machines for choking emergencies.
Response (Greater Manchester Integrated Care): NHS Greater Manchester Integrated Care will share learning from this case with the Greater Manchester System Quality Group and cascade it to professionals through relevant governance and learning forums. The …
Responded
Terence Manning
10 May 2024 · Blackpool & Fylde
Concerns: Inaccurate record-keeping, due to carers transposing details from other residents, led to incorrect dietary information for a resident, posing a risk to future patient safety.
Response (Haddon Court Rest Home): Haddon Court Rest Home has reminded staff about the importance of accurate record keeping and the risks of using the "repeat functionality" of their software; the software provider is reviewing …
Responded
Margaret Taylor
12 Aug 2025 · Gloucestershire
Concerns: A patient was removed from a soft food diet without proper assessment or documentation, and external food was not checked for suitability by care home staff, risking future deaths.
Response (Oak Tree Mews Care Home): Oak Tree Mews Care Home has implemented changes including a new manager, full pre-assessments, updated care plans, a senior lead appointment, protected lunch times, dining area layout changes, amended staff …
Responded
Select committee recommendations(1)
CQC inspection actions(43)
Nicholas House
The provider must ensure that the nutritional and hydration needs of service users, including preferences and provision of appropriate nutrition, are consistently met.
Must Do
Dr French Memorial Home Limited
Meeting nutritional and hydration needs
Must Do
Reside at Southwood
The provider must ensure that people's nutrition and hydration needs are met.
Must Do
Cary Lodge
People did not receive appropriate care that met their needs. Where meeting people's nutritional needs, the provider did not always have regard for people's well-being. 9(1)(a)(b)(2)(3)(i)
Must Do
Talbot House
Further improvements could be made to provide fresh food and less reliance on ready meals to enable people to make personalised choices about their meals.
Should Do
Cygnet Bury Hudson
The service should consider ways to improve the quality of the food given considering the poor feedback from patients directly and within surveys.
Should Do
Woodland Care Home
The nutritional and hydration needs of service users must be met.
Must Do
St.Theresa's Nursing Home
It is recommended that the quality of the food delivered to people using the service is improved.
Should Do
Reside at Southwood
people's nutrition and hydration needs were not being met. Advice from health care professionals was not always sought or followed up, to ensure people received care in a safe way.
Must Do
Oakleigh House Nursing Home
Service users' nutritional needs did not always show regards for their well-being. Regulation 9 (3) (i).
Must Do
Mead Lodge Residential Care
Improvements were required to how the service supported people living with advanced dementia to choose their meals. It was unclear how they could make a meaningful choice and there was limited information available about their preferences for staff to support …
Should Do
Kingsley Nursing Home
The registered manager and provider failed to ensure that people had adequate nutrition and hydration to maintain their health and well-being. 14 (1)
Must Do
Gledhow Lodge
We recommend the provider consider best practice guidance around meeting people's nutritional needs and monitoring their health and wellbeing.
Should Do
Faith Global Links Ventures Limited
The provider had failed to ensure there was a variety of nutritious, appetising food available to meet people's needs.
Must Do
Etherley Lodge
The provider must ensure that care plans and risk assessments are in place for people’s nutrition, including specific dietary requirements and choices, to protect people from risks of inadequate nutrition and related health problems.
Must Do
Chatting Independently Limited - Orchard View
The provider must ensure people are protected from the risk of inadequate nutrition and hydration by means of the provision of a choice of suitable and nutritious food and hydration, and support for the purposes of enabling people to eat …
Must Do
Bourne House
People's nutritional and hydration needs were not always being met with the provision of a suitable healthy and balanced meals in line with people's assessed needs and preferences.
Must Do
Bramble Lodge
Look at how meal times are managed to ensure people are offered choices and their preferences are met, including addressing issues such as inaccessible menus, lack of routine offering of dessert/drink alternatives, and delays in providing assistance to eat meals.
Should Do
Aspen Lodge
We recommend the provider review's people's mealtime experiences including the atmosphere within the dining room and informs people of their planned meals and alternatives before each meal is served.
Should Do
Woodland Care Home
The registered manager committed to reviewing and improving their approach to supporting people to choose healthier meal options.
Should Do
Chiltern View
The provider must ensure people are protected from the risk of malnourishment and dehydration.
Must Do
The Peter Gidney Neurodisability Centre
We recommend the provider consults with residents about menu choices and that the dining experience is improved.
Should Do
Ridgeway Manor Residential Care Home
People who had needs in relation to eating and drinking were not supported to eat and drink safely in a manner consistent with relevant professional guidelines.
Must Do
Friary Lodge
The provider should research good practice guidance in relation to menu planning and assisting people to make informed choices.
Should Do
Eastside House
We recommend that the provider reviews their procedure for deciding what foods are on the menus and evidence that this reflects people's choices.
Should Do
Mead Lodge Residential Care
1.The nutritional and hydration needs of service users must be met. 2.Paragraph (1) applies where— a.care or treatment involves— the provision of accommodation by the service provider, or an overnight stay for the service user on premises used by the …
Must Do
Floron Residential Home for the Elderly
We recommend the provider seeks good practice guidance in relation to supporting nutritional meal choices.
Should Do
Cedar House
We recommend that the provider seek and implement national guidance on providing appropriate meals for older people living in residential care.
Should Do
Brushwood
We recommend the provider undertakes a review of the mealtime experience, consults with people who use the service about meal choices and take action to update their practice accordingly.
Should Do
Bellevue Healthcare Limited
The provider must ensure people receive safe care and treatment, specifically regarding nutrition and hydration to prevent malnutrition and dehydration.
Must Do
Bellevue Healthcare Limited
The provider must ensure the nutritional and hydration needs of service users are met.
Must Do
Ashmore House
The provider must ensure people receive suitable and nutritious food which is adequate to maintain good health and meet their reasonable preferences.
Must Do
Ashcroft House - Leeds
The provider must comply with Regulation 14: Meeting nutrition and hydration needs of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Must Do
Willow Brook House
This could be improved further with visible choices of meals for people to choose from.
Should Do
Ridgeway Manor Residential Care Home
We recommend the provider consider and implement best practice guidance on the preparation and presentation of texture-modified food.
Should Do
Oak Tree Manor
Although there was a menu on the wall of the dining room, this was not especially visible to people and there was no reminder to people prior to lunch being served.
Should Do
Kingfishers Nursing Home
The service provides clear communication and documentation to people that alternative food and drink choices are available.
Should Do
Homesaints Limited
The provider should consider current guidance on recording food and fluid input and take action to update their practice accordingly.
Should Do
Homesaints Limited
The provider should ensure people's meals and drinks are clearly recorded.
Should Do
Holly Court Care Home
The provider needed to improve the environment so that people had a better dining experience. We were not assured that there were enough dining seats for people should everyone choose to eat in the dining room. Daily menus were not …
Should Do
Barton Park Nursing Home
The service reviews their process for recreational activities for people and takes action accordingly.
Should Do
The Warren Residential Lodge
Minutes of meetings showed the manager had engaged with people and their relatives to review the available meals and consider new menus which encompassed people's preferences and offered more choice. This was work in progress and staff told us menus …
Should Do
Bindon Residential Home
The provider must ensure compliance with Regulation 14 (Meeting nutritional and hydration needs) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Must Do
PPO death in custody recommendations(1)
IMB annual reports(5)
Hull (2023)
HMP Hull, a Category B local prison, reported generally safe conditions with violence rates below benchmarks and commendable staff-prisoner relationships. However, significant concerns persist regarding systemic overcrowding, inadequate double-cell accommodation, and insufficient catering budgets impacting food quality. Healthcare provision has improved following a change in contractors, but challenges remain with GP availability and access to specialist mental health care, alongside staffing shortages in other key areas.
PRISON Key concerns
Five Wells (2023)
HMP Five Wells, a Category C prison, opened in February 2022 and housed 1200 prisoners by March 2023, below its operational capacity of 1680. The IMB noted successes such as positive visitor feedback and streamlined safeguarding, but raised significant concerns including widespread illicit items, severe staffing shortages, and numerous design flaws in the new build. Key areas needing development involve consistent regime application, improved food and canteen services, and the re-establishment of resettlement-focused programmes like ROTL.
PRISON Key concerns
Featherstone (2024)
HMP Featherstone faced challenges including the dilapidated state of its facilities, persistent issues with property management, and stretched healthcare services, particularly for mental health. However, the Board observed improvements in staffing levels, education provision, and reduced waiting times for doctors and dentists. Key concerns remain around the prison's aging infrastructure, the treatment of mentally unwell prisoners in segregation, and inconsistent staff culture.
PRISON Key concerns
Altcourse (2025)
HMP Altcourse experienced a challenging reporting year due to significant prisoner movement and increased population, impacting various aspects of prison life from reception to resettlement. While positive strides were made in staff-prisoner relationships, key worker schemes, and diversified mental health provision, critical issues persist. Key concerns include the inadequacy of kitchen facilities, lack of education in segregation, delays in mental health transfers, and a high proportion of prisoners released without accommodation.
PRISON Key concerns
Bure (2025)
HMP Bure, a Category C training prison for sexual offenders, holds 639 prisoners against an operational capacity of 643. While commendable for humane treatment, high time out of cell, and low violence metrics, the Board identifies critical challenges. These include budget cuts impacting education and purposeful activity, inadequate healthcare for the aging population, and persistent staffing shortages affecting regime and support. National policy issues around prisoner wages and property management also remain significant concerns for the Board.
PRISON Key concerns
IMB individual recommendations(51)— showing 50 strongest matches
North East Midlands, Yorkshire & Humber STHF (2023)
In general, we are satisfied that sufficient food choices for different tastes, cultural, religious or medical food requirements are available although we found a significant exception to this on one of our port visits. We recommend all STHFs have arrangements in place that give adequate choices that recognise different food requirements.
Home Office
Oakwood (2024)
The Board is concerned by the widespread dissatisfaction among prisoners of the current food provision. How can the Director ensure that the issues raised are listened to and practical solutions are explored to try to reduce this level of discontent?
Governor / Director
Parc (2022)
Complaints continued regarding food, raising questions over quality, quantity and choice. This raises several questions such as when the provision of food was last reviewed and whether a nutritionist is involved in the process. There is a need to review the catering provision at Parc.
Governor / Director
Parc (2023)
Put in place a process whereby prisoners’ food is regularly assessed for nutritional value, calorific content, quality and quantity.
Governor / Director Implemented
Parc (2023)
Set a minimum spend per prisoner to ensure food supplied offers both quantity and quality along with nutritional value to satisfy prisoners’ calorific needs, as it is unreasonable that prisoners have to supplement their food intake by purchasing from the prison canteen.
HMPPS Noted
Lincoln (2024)
Are there plans to increase the prisoner’s daily food allowance, as providing nutritional meals is increasingly difficult?
HMPPS Implemented
Lincoln (2025)
The Board recommends that plans are made to increase the prisoner’s daily food allowance as providing nutritional meals is increasingly difficult.
HMPPS In Progress
Altcourse (2020)
The food provided to prisoners is an area that has concerned the Board for a number of years. Although there have been some improvements, particularly in the latter part of the reporting year, more still needs to be done in terms of consistency in the quality of the food, and the timely maintenance of kitchen equipment.
Governor / Director
Wormwood Scrubs (2021)
Given that there is acknowledgement within the prison that the food, its production and nutritional value and its quantity are an issue, can the Governor consider with some urgency how this can be remedied? If there is to be consultation, the Board suggests that this should be done speedily.
Governor / Director
Woodhill (2021)
To review the per-day funding allocation for food and to ensure that prisoners are able to access, for example, five portions of fruit and vegetables a day, in line with current Department of Health and Social Care guidance
Other Implemented
Wayland (2021)
The Board understands that the per diem allowance of prison catering has remained at £2.02 for many years. It is the Board’s view that an increase per diem would create greater prisoner satisfaction with a fundamental aspect of the prison’s care for its prisoners and thereby encourage their positive response to the regime as a whole (see section 5.1).
Other In Progress
Onley (2023)
Will there be any review of the food budget, which appears insufficient to ensure that prisoner meals are of a sufficient quality and quantity?
HMPPS
North East Midlands, Yorkshire & Humber STHF (2023)
In locations where detentions are predictably frequent or scheduled in advance, we recommend that a selection of fresh fruit is available for those detained. We appreciate this is not necessarily viable in some port locations where detentions are less frequent and unpredictable. Some STHFs have water readily available for people who are detained, either through a water dispenser or bottled …
Other
North East Midlands, Yorkshire & Humber STHF (2023)
In locations where detentions are predictably frequent or scheduled in advance, we recommend that a selection of fresh fruit is available for those detained. We appreciate this is not necessarily viable in some port locations where detentions are less frequent and unpredictable. Some STHFs have water readily available for people who are detained, either through a water dispenser or bottled …
Home Office
Parc (2024)
Put in place a process whereby prisoners’ food is regularly assessed for nutritional value, calorific content, quality and quantity.
Governor / Director
Parc (2024)
Set a minimum spend per prisoner to ensure food supplied offers both quantity and quality along with nutritional value to satisfy prisoners’ calorific needs, as it is unreasonable that prisoners have to supplement their food intake by purchasing from the prison canteen.
HMPPS
Stoke Heath (2025)
Prisoners complain to the IMB about the quality and quantity of food they receive. Will the Governor make a concerted effort to reduce food waste by improving food quality?
Governor / Director In Progress
Stoke Heath (2025)
The IMB receives many complaints about the food, especially the lunchtime options. The budget per capita is well below that provided for schools. Will the Prison Service provide resource to improve the food options available to prisoners?
HMPPS In Progress
Moorland (2020)
Can the national daily budgetary allowance for food be reviewed, to ensure sufficient nutrition for all prisoners?
HMPPS In Progress
Winchester (2021)
Can the canteen list include more items of fresh fruit and vegetable for prisoners who wish to purchase them? (See section 5.1).
HMPPS In Progress
Moorland (2021)
The Board requests that the national daily budgetary allowance for food be reviewed on a national level to ensure that prisoners are receiving adequate nutrition.
HMPPS Noted
Whitemoor (2022)
Will HMPPS review the way in which prisoners in high security prisons are fed, taking into account the facilities and equipment supplied for the main kitchen; the qualifications of staff; the budget allowed for the purchase of food; the canteen and its approach to pricing?
HMPPS
Warren Hill (2022)
In light of ongoing concerns about the provision of food from the Hollesley Bay kitchen, the Board asks again that consideration be given to reinstating the kitchens at Warren Hill
HMPPS
Oakwood (2022)
The Board continues to be concerned about prisoners in the servery not wearing the appropriate personal protective equipment (PPE) and clothing. Notwithstanding that Aramark provided continuity of a balanced menu and two cooked meals a day, the Board is still concerned about the quality, quantity and variety of the food provided and the ensuing waste that results, and that the …
Governor / Director
Norwich (2022)
Will the Minister please outline his plan for aligning the catering budget with the increases in the cost of living to ensure prisoners can be offered a balanced and nutritious diet?
Ministry of Justice Noted
Morton Hall (2022)
reducing the rate of returns for canteen goods and in particular ensuring a satisfactory quality of food items, notably cheese and fresh fruit, and ensuring that prisoner returns are refunded promptly (see paragraph 5.1.8)
Governor / Director
Moorland (2022)
Once again, the Board is requesting that the food budget is increased
Governor / Director
East Sutton Park (2022)
To review the contents of the canteen list more regularly to ensure that it is relevant to the needs of the residents.
Governor / Director
Thorn Cross (2023)
To reconsider the current proposals for central dining (5.1.4).
Governor / Director
Morton Hall (2023)
Enforcing the DHL contract (which delivers canteen items to the prison) to reduce the rate of returns for canteen goods and, in particular, ensuring: (a) a satisfactory quality of fresh food items; and (b) a regular and reliable supply of advertised items (paragraph 5.1.9).
HMPPS In Progress
Morton Hall (2023)
Increasing the daily food cost allowance, given levels of food cost inflation and the current reliance on carbohydrates (paragraphs 5.1.2, 5.1.10; Annexes 3 and Applications to the IMB).
HMPPS Implemented
Hull (2023)
The Governor should ensure all reasonable steps are taken to improve food quality (notably lunch time offering), whilst continuing to work within very restricted budgetary constraints (see also ‘to the Prison Service).
Governor / Director
High Down (2023)
What steps can be taken to improve cleanliness in the houseblock serveries and improve portion control to ensure all prisoners receive enough food?
Governor / Director
Frankland (2023)
The preparation of food for religious beliefs often challenges an already limited daily prison meal allowance. When will the Minister raise the allowance, in line with the rise in the cost of food?
Ministry of Justice Noted
Five Wells (2023)
What steps are being taken to ensure a good standard of food is available for prisoners, and food safety requirements are met?
Governor / Director
Derwentside IRC (2023)
To improve the quality and variety of the food served to the detained women.
Governor / Director
Thorn Cross (2024)
To reconsider the current proposals for central food/dining.
Governor / Director
Hull (2024)
Will the Prison Service be increasing catering budget allocations in response to increased food supplier costs to ensure a healthy and balanced diet can be provided to each prisoner?
HMPPS Implemented
Cardiff (2024)
The Board believes the process for provision of specific dietary needs should be reviewed and improvements made where possible.
Governor / Director
Belmarsh (2024)
Will the Governor work with the various stakeholders in the procurement and preparation of food to improve the nutritional content and quality?
Governor / Director
Preston (2025)
What steps will the Governor take to ensure that the prison provides good quality meals for prisoners, with adequate provision for special diets? This requires kitchen equipment to be functioning at optimum level.
Governor / Director
Springhill (2021)
The Board queries how long the prison will be able to sustain standards on food based on a budget per head that has remained unchanged for many years (see 5.1.15).
HMPPS Noted
Norwich (2021)
The daily budget for food of £2.02 has not been increased since 2014. Will HMPPs give an indication of when this might be reviewed?
HMPPS Rejected
Garth (2021)
The food budget be increased as a matter of urgency.
HMPPS In Progress
Morton Hall (2022)
to consider increasing the daily food cost allowance, given levels of food cost inflation and the reliance on carbohydrates (see paragraph 5.1.2).
HMPPS
Lincoln (2023)
Are there plans to increase the prisoner’s daily food allowance of £2.20? Inflation continues to rise and providing nutritional meals is increasingly difficult.
HMPPS Implemented
Lewes (2023)
The Board is concerned that, in the light of the cost of living crisis, the prisoner food budget will very soon be insufficient. When will the prison service be reviewing this?
HMPPS
Hull (2023)
Despite a recent uplift in the daily budget allocation per prisoner for catering, the establishment continues to provide additional funding from other budget allocations. Furthermore, prisoners were found to subsiding their diets with their own personal funds. Will the Prison Service be significantly increasing catering budget allocations in response to increased food supplier costs to ensure a healthy and balanced …
HMPPS
Derwentside IRC (2023)
To ensure that the processes for identifying and catering for food allergies are completely failsafe.
Governor / Director
Werrington (2024)
Are the food portions issued to young people, who are physically developing, adequate for their age?
HMPPS Implemented
Detention investigations(4)
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R18
Managers should ensure that menus:  offer adequate appetising fresh fruit and vegetables and encourage the consumption of five portions of fruit and vegetables a day; and  offer a better-balanced choice of foods at lunchtimes.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R20
Serco should consider how residents might be given greater opportunities to cater for themselves, including by expanding the cultural kitchen facilities, the choice of foods in the shop and providing facilities for residents to store and cook food and make snacks for themselves.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 30
In my earlier report on Yarl’s Wood, I recommended that GSL should work closely with Aramark to ensure that meals meet as wide a range of cultural needs as possible, and that, given the ever-changing population, the menu on offer should be kept constantly under review. I repeat that recommendation …
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R21
Serco should work with the Home Office to ensure that the current DSO on food and fluid refusal is appropriately amended to make it explicit that residents who prefer to cater for themselves can do so without automatically being subject to ACDT.
Immigration Detention
PHSO casework decisions(27)
P-001063 — East Kent Hospitals University NHS Foundation Trust
Miss A complained her father received inadequate nutrition, Parkinson's medication, physiotherapy, and pressure sore management, experiencing poor care and staff rudeness.
NHS in England Upheld Apr 2021
P-002635 — Epsom and St Helier University Hospitals NHS Trust
Miss T complained the Trust failed to provide her father adequate nutrition, delayed dietitian referral, and did not consider alternative feeding methods, contributing to his death.
NHS in England Upheld May 2024
P-002916 — Barts Health NHS Trust
Ms P complained the Trust failed to prescribe pneumonia medication, provide pain relief/antibiotics, offer suitable food, withdrew antibiotics without consent, and poorly communicated her father's deterioration.
NHS in England Sep 2024
P-003349 — Mid and South Essex NHS Foundation Trust
Staff allegedly failed to provide adequate nutrition/hydration, ensure physiotherapy, and discharged Mr I when he was unfit, leading to his death after nine days.
NHS in England Partly Upheld Feb 2025
P-003662 — Bedfordshire Hospitals NHS Foundation Trust
Mrs L complained the Trust failed to support her father's nutrition, oral care, and mobility, or provide physiotherapy after discharge, which she believes led to his death.
NHS in England Partly Upheld Jul 2025
P-002588 — County Durham and Darlington NHS Foundation Trust
Mrs T complained her father received inadequate food and drink, lacked mobility efforts, and had poor record keeping, contributing to his declining condition and death.
NHS in England Partly Upheld May 2024
P-002832 — United Lincolnshire Hospitals NHS Trust
Ms O complained the Trust poorly communicated, failed to provide an appropriate diet, delayed rehabilitation, and poorly coordinated her brother's discharge, which she said contributed to his death. She also cited poor ED care.
NHS in England Upheld Jul 2024
P-003065 — Royal Cornwall Hospitals NHS Trust
Miss E complained the Trust failed to provide her mother with correct nutrition, dental care, or treat her delirium during hospital admission. She believed this led to rapid deterioration and earlier death.
NHS in England Oct 2024
P-003362 — Northern Lincolnshire and Goole NHS Foundation Trust
Miss S complained the Trust failed to disclose her mother's diagnosis and adequately meet her nutrition and hydration needs, causing distress and concern about hastened deterioration. She also cited poor end-of-life care planning and communication.
NHS in England Upheld Feb 2025
P-003464 — Cambridgeshire and Peterborough NHS Foundation Trust
Miss P complained the Trust failed to appropriately mobilise her mother, mismanaged her nutritional needs, and prevented family visits, allegedly contributing to her mother's deterioration and death.
NHS in England Mar 2025
P-003427 — Croydon Health Services NHS Trust
Mr H alleged the Trust failed to provide his mother with adequate nutrition and proper diabetes control, including medication errors, which he believes hindered her recovery and cancer treatment.
NHS in England Partly Upheld Mar 2025
P-003459 — University Hospitals Birmingham NHS Foundation Trust
Mr X complained the Trust prematurely placed a DNR notice, failed to manage pneumonia recovery, inadequately managed nutrition, and didn't act on sepsis signs, leading to his mother's death.
NHS in England Mar 2025
P-004079 — University Hospitals Coventry and Warwickshire NHS Trust
The Trust dismissed her mother's symptoms, delayed surgery, provided poor nutritional care, misused a feeding tube, and communicated poorly, leading to declining health and an undignified death.
NHS in England Partly Upheld Sep 2025
P-004162 — Wirral University Teaching Hospital NHS Foundation Trust
Mr A complained the Trust gave his wife an antibiotic without informing him, left her on a trolley too long, didn't assist her mobilisation, and provided inappropriate nutrition.
NHS in England Partly Upheld Oct 2025
P-004333 — Royal Berkshire NHS Foundation Trust
Miss P complained the Trust failed to provide adequate hydration and nutrition for her mother, and isolated her without an alert system, impacting her physical and mental condition.
NHS in England Partly Upheld Nov 2025
P-004430 — Dartford and Gravesham NHS Trust
A daughter complained her father received inadequate nutrition and fluids, delayed feeding tube insertion, poor supervision, and insufficient toileting assistance across multiple wards.
NHS in England Dec 2025
P-001316 — University Hospitals Birmingham NHS Foundation Trust
Daughter complained about inadequate monitoring and treatment of her mother's weight loss, nutrition, and mismanagement of a pressure ulcer by the Trust.
NHS in England Partly Upheld Feb 2022
P-001798 — Bolton NHS Foundation Trust
Miss I complained her late mother received inadequate care, including poor nutrition support, lost hearing aids, denied visits, and an uninvestigated assault by another patient.
NHS in England Feb 2023
P-002674 — University Hospitals Coventry and Warwickshire NHS Trust
Mrs G complained about multiple failings in Miss O's care, including delayed investigation/treatment, improper discharges, and poor communication, which she believed led to Miss O's death.
NHS in England Jun 2024
P-004501 — Stockport NHS Foundation Trust
Ms C complained about her mother's inpatient care, citing failures in COVID-19 visiting rules, nutrition, discharge supplies, catheter communication, and lack of end-of-life care information.
NHS in England Partly Upheld Dec 2025
P-001306 — Mid Yorkshire Hospitals NHS Trust
Miss U complained the Trust failed to provide her father with adequate nutritional intake and IV fluids, which she believed worsened his condition and contributed to his death.
NHS in England Not Upheld Feb 2022
P-001499 — United Lincolnshire Hospitals NHS Trust
Mr E complained the Trust did not properly manage his late wife's nutritional requirements or administer her regular medicines, questioning if better care could have prolonged her life.
NHS in England Aug 2022
P-002900 — King's College Hospital NHS Foundation Trust
Mrs A complained her elderly mother suffered from delayed hospital admission, inadequate hydration/nutrition, and untreated lung aspiration, leading to her death.
NHS in England Aug 2024
P-003248 — A practice in the Trafford area
Miss R complained about delays in her mother's ring pessary replacement and the Trust's refusal to provide incontinence briefs, potentially contributing to UTIs and her mother's death.
NHS in England Dec 2024
P-004160 — Mid and South Essex NHS Foundation Trust
Mrs G complained the Trust administered dapagliflozin without monitoring, failed to provide nutrition, and delayed Mr G's bypass surgery, leading to HHS, a heart attack, and his death.
NHS in England Partly Upheld Oct 2025
P-004155 — Epsom and St Helier University Hospitals NHS Trust
Mrs S complained the Trust failed to diagnose/treat her mother's swallowing, maintain nutrition, and administered high diazepam doses, contributing to her death.
NHS in England Oct 2025
P-001890 — Sandwell and West Birmingham Hospitals NHS Trust
Mr R complained his father received incorrect pureed food from the Trust, which he believes led to pneumonia and ultimately caused his father’s death.
NHS in England Mar 2023
LGO / SPSO decisions(15)
21-000-498b — Brighton & Hove Clinical Commissioning Group (21 000 …
Summary: The Ombudsmen found no fault by a Council, a CCG and a care home in relation to the nutritional support and personal care provided to Mrs Y. We have found fault with how nutritional risk was assessed, but this did not affect the care provided and the care home …
LGO (Local Government & … Health Not Upheld Jan 2022
21-000-498 — Brighton & Hove City Council
Summary: The Ombudsmen found no fault by a Council, a CCG and a care home in relation to the nutritional support and personal care provided to Mrs Y. We have found fault with how nutritional risk was assessed, but this did not affect the care provided and the care home …
LGO (Local Government & … Adult Care Services Upheld Jan 2022
21-017-088 — Greensleeves Homes Trust
Summary: Ms C complains the Care Provider failed to support Mrs D which resulted in her premature death. The Care Provider failed to record decisions, follow care plans, monitor Mrs D’s nutrition needs, and properly respond to Ms C’s complaints. Ms C has the uncertainty of not knowing, but for …
LGO (Local Government & … Adult Care Services Upheld Sep 2022
201002248 — Lothian NHS Board
Mrs A was an elderly resident of a nursing home. She suffered from severe Alzheimer’s disease and a range of other health problems. She was admitted to hospital for assessment as she was becoming increasingly agitated. At the time of admission, Mrs A had a wound on her left leg. …
SPSO (Scottish Public Se… Health Partly Upheld Jun 2011
24-021-792 — Cambridgeshire County Council
Summary: The Council’s commissioned care provider failed to provide a good standard of care for the late Mrs X, failed to keep proper records in accordance with the regulations and did not provide her nutrition in accordance with the hospital discharge instructions. The Council agrees to recognise the considerable distress …
LGO (Local Government & … Adult Care Services Upheld Dec 2025
21-004-194 — Stockport Metropolitan Borough Council
Summary: The Council was at fault, because it did not offer the complainant’s mother an affordable care home placement, before asking her to pay a top-up towards her mother’s fees. This meant the top-up arrangement did not adhere with the statutory guidance. The Council has agreed to remedy the injustice …
LGO (Local Government & … Adult Care Services Upheld Mar 2022
201100382 — Greater Glasgow and Clyde NHS Board - Acute …
Mrs C complained about the food and about failure to provide a raised toilet seat, a blanket and sleeping pills during her three-day admission to a hospital. We concluded that the board had not acted unreasonably in respect of the food provided. In respect of the other issues, we concluded …
SPSO (Scottish Public Se… Health Not Upheld Aug 2011
201202478 — Scottish Prison Service
Mr C, who is a prisoner, complained to the prison that the lunchtime meal had been adulterated (made impure or inferior by adding foreign substances) and was excessively salty. In taking his complaint to the prison's internal complaints committee (ICC), Mr C requested to call the catering manager as a …
SPSO (Scottish Public Se… Prisons Upheld Dec 2012
201400127 — Scottish Prison Service
Mr C, who is a prisoner, complained that the prison had not put measures in place to assist with his special dietary requirements. He made suggestions to prison staff as to what might help overcome the problem and was unhappy that they did not respond favourably to these. He left …
SPSO (Scottish Public Se… Prisons Not Upheld Sep 2014
202203333 — East Renfrewshire Health and Social Care Partnership
C complained on behalf of a relative (A) who had a learning disability and had been prescribed a special adjusted diet according to the International Dysphagia Diet Standardisation Initiative (IDDSI) guidelines. A had choked on their food and required emergency care. C complained that A’s food, a takeaway meal, had …
SPSO (Scottish Public Se… Health and Social Care Partly Upheld Nov 2024
22-007-561 — Lancashire County Council
Summary: We will not investigate this complaint about the Council increasing Mr X’s parent’s assessed contributions towards the cost of their care and failing to inform them of this in writing. This is because there is insufficient evidence of fault to justify an investigation.
LGO (Local Government & … Adult Care Services Oct 2022
25-003-464 — Bath and North East Somerset Council
Summary: We will not investigate Mr X’s complaint, brought by Miss Y, about the Council’s decision to include Mr X’s main residence as an asset available for use in paying care fees when calculating his finances and asking him to separately register the flats in the property to realise them …
LGO (Local Government & … Adult Care Services Sep 2025
201005150 — Lothian NHS Board
Ms C, who is a vegan, was scheduled to have an operation in the day surgery unit (DSU) at the Royal Infirmary Edinburgh. At her pre-operative assessment she arranged for vegan food to be available. Ms C also suffers from a severe and chronic condition that is worsened by exertion, …
SPSO (Scottish Public Se… Health Partly Upheld Jul 2011
201304894 — Scottish Prison Service
Mr C complained that the prison he was in failed to make adequate arrangements for the provision of halal food. He said that he wanted the imam for the prison to taste random halal meals, as he considered that the halal goods brought into the prison were not halal by …
SPSO (Scottish Public Se… Prisons Not Upheld Jan 2015
201704678 — Scottish Prison Service
Mr C complained that he did not receive his meals in prison when he was off his work placement for a week. He has a nut allergy and had requested to be placed on a special diet list. His work placement was within the kitchens so he was usually able …
SPSO (Scottish Public Se… Prisons Upheld Nov 2018
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