Dear Ms Saunders,

Re: Regulation 28 Response

I am writing to provide Velindre University NHS Trust’s formal response to the Regulation 28 Report issued on the 6th October 2025 following the inquest into the death of Mr. Steven Paul Turzynski.

I would like to start by thanking you for raising these extremely important matters with the Trust and to apologise for the failings identified through the inquest process. Velindre University NHS Trust both acknowledges and accepts the concerns raised relating to the adequacy of nutritional assessment, communication between dietetic teams, and the need for strengthened standards for face-to-face consultations for patients receiving cancer treatment. We fully recognise the significant role that appropriate nutritional support plays in ensuring safe and effective cancer care, and the serious implications when those standards are not met.

The Trust has undertaken a comprehensive review of practice and implemented targeted

Pencadlys Ymddiriedolaeth GIG Prifysgol Felindre Velindre University NHS Trust Headquarters 2 Cwrt Charnwood Heol Billingsley Parc Nantgarw Caerdydd/Cardiff CF15 7QZ

Ffôn/Phone: (029) 20196161

Mae Ymddiriedolaeth GIG Prifysgol Felindre yn hapus i dderbyn gohebiaeth yn y Gymraeg neu’r Saesneg. Velindre University NHS Trust is happy to receive communication in Welsh or English. improvement actions. We continue to work closely with Aneurin Bevan University Health Board (ABUHB), reflecting the joint nature of this Prevention of Future Deaths (PFD) Report, to ensure that safe, consistent and coordinated dietetics care is provided across organisational boundaries.

I have attached the Trust’s improvement plan that has been developed in conjunction with ABUHB for reference.

For ease of reading I have detailed below the specific actions undertaken and those in progress to reduce the likelihood of similar circumstances arising in the future:

Development & Improvement

To ensure sustained system-wide improvements, Velindre Cancer Service has strengthened its governance arrangements relating to dietetic care, including enhanced reporting mechanisms, improved visibility of service risks, and increased oversight of multi-professional clinical standards. We have implemented a series of measures to improve co-working and communication between hospital and community dietetic services, including:

• A joint communication protocol and Multi-Disciplinary Team checklist to standardise the processes for shared care patients

• Quarterly joint dietetic meetings with ABUHB to support shared learning and early escalation of any potential risks or issues

• Review and confirmation of Upper Gastrointestinal and Head & Neck clinical pathways

• Development of an interim shared care transfer document until the All-Wales standard is formally approved

Pencadlys Ymddiriedolaeth GIG Prifysgol Felindre Velindre University NHS Trust Headquarters 2 Cwrt Charnwood Heol Billingsley Parc Nantgarw Caerdydd/Cardiff CF15 7QZ

Ffôn/Phone: (029) 20196161

Mae Ymddiriedolaeth GIG Prifysgol Felindre yn hapus i dderbyn gohebiaeth yn y Gymraeg neu’r Saesneg. Velindre University NHS Trust is happy to receive communication in Welsh or English.

• Active engagement with the Welsh Dietetic Leaders Advisory Group (WDLAG) to strengthen cross-boundary referral processes

The above steps will ensure that dietitians in different hospitals can share information across organisational boundaries, understand who is responsible for each patient, and provide consistent nutritional advice. Patients will no longer receive conflicting information as both teams will have shared visibility and direct contact pathways. Cross site interface meetings will facilitate shared learning and information sharing.

We also recognised following the inquest the risk of not seeing patients face to face and we have developed plans and guidelines to ensure the adequacy of dietetic assessments over the phone, and a minimum standard set for face-to-face consultations. The steps we have taken to date include benchmarking locally, regionally and nationally to help inform the development of a draft Standard Operating Procedure which, following approval, will be evaluated to ensure that it is embedded into practice.

Governance and Monitoring

To provide assurance of ongoing monitoring, evaluation and sustained improvements any Improvement work is overseen through the Velindre Cancer Service Quality & Safety governance structure. Progress is monitored via the Trust’s electronic regulatory and assurance tracker and is reported to the Executive Management Board and Quality, Safety and Performance Committee. Monthly joint meetings with ABUHB ensure close alignment and shared accountability in relation to our shared improvement actions. We have written to Mr Turzynski’s partner to express our sincere apologies that the care provided did not meet the standards to which we are committed, and we have offered the opportunity to meet with the clinical team. I hope that this response provides you with the assurance required that the action we have taken is robust enough to prevent future deaths related to dietetic support and provision.

Pencadlys Ymddiriedolaeth GIG Prifysgol Felindre Velindre University NHS Trust Headquarters 2 Cwrt Charnwood Heol Billingsley Parc Nantgarw Caerdydd/Cardiff CF15 7QZ

Ffôn/Phone: (029) 20196161

Mae Ymddiriedolaeth GIG Prifysgol Felindre yn hapus i dderbyn gohebiaeth yn y Gymraeg neu’r Saesneg. Velindre University NHS Trust is happy to receive communication in Welsh or English.

Please do not hesitate to contact me if I can provide any further information. I am truly sorry for the issues that have been found and for the impact that these have had on Mr. Turzynski and his family. I hope to assure you that, as a Trust, we are committed to continuously striving to improve the care that we provide to all our patients.

Dear Ms Saunders

Response to Regulation 28 Report received following the inquest touching on the death of Steven Paul Turzynski

Thank you for your letter and accompanying report, which the Health Board received on 6 October
2025. This letter provides the Health Board’s formal response to the Regulation 28 Report to prevent future deaths following the inquest into the death of Mr Steven Paul Turzynski.

To provide assurance that meaningful and lasting improvements are being achieved across the Health Board, we have implemented a strengthened governance framework dedicated to nutrition and hydration. This framework enhances organisational coordination, ensures accountability for quality improvement, and embeds systematic oversight within our Quality Management System.

At its core, the framework consists of a Strategic Nutrition and Hydration Group, supported by two operational sub-groups. Each group has clearly defined roles, multi-professional membership, and a direct reporting route from frontline practice to board assurance, ensuring that clinical and operational perspectives are aligned.

The Strategic Group provides senior clinical leadership and organisational assurance. Chaired by the Assistant Director for Allied Health Professions and Health Science, it includes senior representatives from Nursing, Medicine, Finance, Digital, and Quality & Patient Safety. The inclusion of Llais within its membership ensures that the views and experiences of patients and service users inform all improvement activity. Meeting every two months, the group reviews incident themes, monitors risk registers, and oversees progress against strategic improvement priorities. It also acts as an expert reference group for the wider organisation on all matters relating to nutrition and hydration safety.

Two operational groups report into this structure:  Food Standards Group – responsible for operational oversight of food service delivery, dietary standards and compliance with the All-Wales Nutrition and Catering Standards for

Food and Fluid Provision for Hospital Inpatients. It meets monthly to review incidents, drive service improvements, and escalate key issues to the Strategic Group  Clinical Standards Group – overseeing clinical practice in relation to nutrition and hydration across acute, community, maternity, paediatric and older adult services. The group monitors, compliance and leads on risk-assessment processes and ensures that clinical standards are applied consistently across all care settings

This governance model has already accelerated the delivery of targeted improvements, such as enhanced nutritional screening, included in our ward accreditation programme, monitoring of fluid balance, strengthened escalation processes for patients at risk of malnutrition, and improved documentation standards. These developments are now being embedded into routine practice through the Quality Management System, supporting a proactive and transparent approach to preventing avoidable harm. The Health Board has also recently created and successfully appointed the first Consultant Dietitian post in Wales with a specific remit for Nutrition and Hydration. This senior clinical leader will embed Nutrition and Hydration at the core of our clinical care and strategically in our policies and clinical pathways.

In summary, this framework provides the Health Board with strong clinical leadership, effective operational alignment, and meaningful service-user involvement in the ongoing improvement of nutrition and hydration care. It offers a clear mechanism for ensuring that learning from incidents leads to sustainable, system-wide change.

The information below outlines the specific actions undertaken and those in progress to reduce the likelihood of similar circumstances arising in the future. These are detailed within the accompanying multi-professional improvement plan appended to this letter.

1. Communication and Information Sharing Between Health Boards

Assurance Statement Aneurin Bevan University Health Board (ABUHB) and Velindre University NHS Trust (VUNHST) recognise the coroner’s concern that inadequate communication between each organisations dietetic teams contributed to suboptimal nutritional management. Both organisations are committed to strengthening the safety and consistency of information exchange for all patients whose care is transferred across organisational boundaries.

Planned / Ongoing Actions  Joint Transfer of Care Standard Operating Procedure (SOP): A collaborative SOP is being developed between ABUHB and VUHNHST to define clear referral, handover, and documentation standards for patients receiving shared dietetic care. The SOP will outline required content for transfer summaries, response timeframes, and points of professional contact  Shared Access to Clinical Records: Both organisations are reviewing long term digital interoperability options with potential single patient care records, dependant on Digital Health & Care Wales support. In the interim, read only access to ABUHB clinical system (CWS) has been granted to VUHNHST dieticians and WCP access will be granted to appropriate cohort of ABUHB Dietitians

 Multidisciplinary Interface Meetings: Quarterly meetings will be held between ABUHB and VUHNHST dietetic leads to discuss and review any shared oncology cases, clinical incidents, resolve communication issues, and identify opportunities for process improvement

How these actions address the concern These steps ensure that dietitians in different hospitals can share information across organisational boundaries, understand who is responsible for each patient, and provide consistent nutritional advice. Patients will no longer receive conflicting information as both teams will have shared visibility and direct contact pathways. Cross site interface meetings will facilitate shared learning and information sharing.

2. Clinical Standards and Governance for Mode of Dietetic Assessment

Assurance Statement The Health Board acknowledges the coroner’s concern regarding the absence of guidance for determining when dietetic assessments should be conducted face-to-face versus by telephone. The organisation, in collaboration with Velindre, is updating and enhancing existing clinical standards to guide assessment practice and ensure equity and quality of nutritional care

Planned / Ongoing Actions  Dietetic Assessment and Consultation Guideline: Development of an operating protocol to define clinical criteria for the mode of assessment. This will include consideration of disease complexity, nutritional risk, treatment phase, and patient preference. ABUHB booking process being adapted to facilitate face to face review as an initial assessment.  Decision-Making Tool: Decision-making tool to be introduced, requiring clinicians to record their rationale for remote versus in-person assessment in the patient’s notes, promoting transparency and auditability

How these actions address the concern Where a patient is unable or unwilling to travel for an in-person review, a face-to-face assessment will still be arranged through a home visit or other clinically appropriate alternative setting to ensure that frailty, weight loss and nutritional risk are directly assessed.

3. Monitoring, Audit and Continuous Improvement

Assurance Statement The Health Board is committed to ensuring that the above improvements are sustained through regular audit, shared learning, and oversight via established quality governance structures.

Planned / Ongoing Actions  Annual Joint Audit: ABUHB and VUNHST will jointly audit adherence to the Dietetic Transfer of Care Standard Operating Procedure and Assessment Protocol, with findings reported to each organisation’s Nutrition & Hydration Group and/or Quality & Patient Safety assurance group

 Exception and Learning Reporting: Any deficiencies or recurrent communication failures will be logged through Datix and reviewed at joint governance meetings. Themes and learning will be fed into professional development sessions  Workplan Integration: Requisite improvement actions will be included within the ABUHB Nutrition & Hydration Group workplan, with progress reviewed bi-annually and updates shared with VUHNHST governance partners  Quality Assurance: Peer review and clinical supervision sessions will be embedded into dietetic governance structures within ABUHB, focusing initially on oncology cases  Spreading the learning: Dietetics service will present learning from this case at the ABUHB patient quality & safety learning and improvement forum

How these actions address the concern A system of disseminating learning from incidents and regular compliance audits will ensure all staff follow consistent standards when providing dietetic care, regardless of where they work. Lessons learnt from this case will be embedded into professional development and ongoing supervision so that improvements are maintained long term

Governance and monitoring

In parallel with the joint work undertaken with VUHNHST, ABUHB continues to strengthen its own internal systems to ensure that exacting standards of nutrition and hydration care are delivered consistently across all divisions. Locally, this includes the development of enhanced digital documentation tools, strengthened escalation frameworks for patients at nutritional risk, and increased use of clinical supervision and reflective learning within teams.

At a system level, the Health Board and VUHNHST have committed to working in close partnership to maintain and monitor these improvements. Regular joint meetings between both organisations will review progress against the action plan, share emerging learning, and resolve any cross- boundary issues in real time.

An annual joint audit of service quality will also be undertaken to evaluate the effectiveness of the collaborative arrangements and to identify further opportunities for improvement.

Together, these local and joint actions provide assurance that improvements are both organisation- led and system-wide, supporting sustained and measurable progress in the safety and quality of dietetic care.

We accept and are sorry that there were elements of Mr Turzynski’s care that fell below the standards we would want and expect for our patients and appreciate how devastating this has been for his family and we are committed to ensuring that the circumstances surrounding Mr Turzynski’s end of life nutritional care result in meaningful and sustained improvements in communication, record-sharing and dietetic care.