Emily Hewerdine
PFD Report
All Responded
Ref: 2025-0431
All 1 response received
· Deadline: 13 Oct 2025
Coroner's Concerns (AI summary)
Patients faced inadequate hydration assessments and fluid charting, nursing failures to identify deterioration, and a lack of clinical assessment in the Emergency Department before mental health referrals or discharge.
View full coroner's concerns
1. That patients on the wards at Bassetlaw DGH will have inadequate assessments of hydration status, and have inaccurate and inadequate completion of fluid balance charts
2. That nursing assessments, particularly in very vulnerable patients, will not identify a deteriorating patient, thus preventing necessary escalation for medical assessment
3. That there continues to be a risk that no clinical assessment will be undertaken, in patients attending the Emergency Department at Bassetlaw DGH, prior to referral for a mental health assessment , and that there continues to be a risk that no clinical assessment will occur in Emergency Department prior to a patients discharge home I am not reassured that necessary actions to address these serious issues identified are in place.
2. That nursing assessments, particularly in very vulnerable patients, will not identify a deteriorating patient, thus preventing necessary escalation for medical assessment
3. That there continues to be a risk that no clinical assessment will be undertaken, in patients attending the Emergency Department at Bassetlaw DGH, prior to referral for a mental health assessment , and that there continues to be a risk that no clinical assessment will occur in Emergency Department prior to a patients discharge home I am not reassured that necessary actions to address these serious issues identified are in place.
Responses
Action Taken
Doncaster and Bassetlaw Teaching Hospitals implemented measures including weekly audits via Tendable, transition to electronic fluid balance charting, strengthened verbal handover processes, and launched Safety Huddles. All ED patients now undergo a medical review prior to mental health referral, subject to monthly audit. (AI summary)
Doncaster and Bassetlaw Teaching Hospitals implemented measures including weekly audits via Tendable, transition to electronic fluid balance charting, strengthened verbal handover processes, and launched Safety Huddles. All ED patients now undergo a medical review prior to mental health referral, subject to monthly audit. (AI summary)
View full response
Dear Dr Didcock
Regulation 28 – Report to Prevent Future Deaths: Ms Emily Hewerdine
I write to you with respect to the Regulation 28 Report issued on the 28 July 2025 to Chief Executive of Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust following the inquest into the death of Ms Emily Hewerdine.
The report was received by the Chief Executive’s office and forwarded to me in order to provide a response.
Each concern is outlined in bold, followed by the Trust’s response:
Firstly, I would like to take this opportunity to express the Trust’s sincere condolences to the family and friends of Ms Emily Hewerdine.
Concern: That patients on the wards at Bassetlaw District General Hospital (BDGH) may receive inadequate assessments of hydration status, with inaccurate and incomplete fluid balance chart documentation.
Under the Patient Safety Incident Response Framework (PSIRF), one of the Trust’s identified local priorities in 2024 was the recognition and management of the deteriorating patient. In response, a Trust-wide Safety Improvement Plan was developed, which includes targeted actions to improve fluid balance chart accuracy and hydration assessments.
Progress against this plan is monitored through the Trust’s governance structures, specifically the Patient Safety Assurance Group, chaired by the Chief Nurse and attended by the Executive Medical Director.
Following Ms Hewerdine’s case, the Trust commissioned a Patient Safety Incident Investigation (PSII) to identify learning and implement improvements. Measures introduced include:
• Use of Tendable, the Trust’s audit and quality improvement application, enabling weekly audits and monthly oversight by the Matron. Non-compliance triggers ward- level action plans.
• Transition to electronic fluid balance charting, enhancing accuracy and enabling real- time oversight.
• Ongoing education and training initiatives led by the Division of Medicine in collaboration with the Quality Improvement team.
• Implementation of an Acute Kidney Injury (AKI) Care Bundle within the electronic patient record system in pilot areas. This includes prompts for fluid balance chart initiation and completion. Early evaluation indicates improved monitoring, with full Trust-wide rollout planned for February 2026.
Concern: That nursing assessments, particularly in very vulnerable patients, may fail to identify deterioration, preventing timely escalation for medical review.
In 2023–24, the Trust introduced the Care Accreditation and Recognition for Excellence (CARE) Framework, providing structured, objective evaluations of service quality. This framework supports continuous improvement and identifies areas requiring development. The Chief Nurse Oversight Framework complements this by enabling monthly reviews to detect quality triggers. This is a proactive process designed to identify areas requiring escalation and support early.
In 2024–25, nutrition-related indicators were incorporated into the CARE Framework, including:
• Compliance with MUST score assessments.
• Attendance of Link Nurses at quarterly training sessions.
• Peer review visits focused on food intake and mealtime practices.
The Trust also conducts regular Nutrition and Mealtime Peer Reviews, with findings reported to the Nutrition Action Group, which in turn reports to the Patient Safety Assurance Group. This ensures cross-divisional oversight and alignment with the Safety Improvement Plan.
To enhance communication and safety culture:
• Verbal handover processes during shift changes have been strengthened.
• Safety Huddles have been launched Trust-wide and embedded at BDGH. These evidence-based initiatives support real-time identification and escalation of safety concerns. For example, a recent huddle identified a patient declining all oral intake, prompting immediate clinical review.
Additionally, the Division of Medicine are hosting a Gastroenterology Masterclass on 7 October 2025, focusing on multi-disciplinary training. A key component was the importance of comprehensive nutrition and hydration assessments for patients with Inflammatory Bowel Disease (IBD), including accurate fluid input/output monitoring.
Concern: That patients attending the Emergency Department at Bassetlaw DGH may not receive a clinical assessment prior to referral for mental health evaluation or prior to discharge. Divisional Director, has formally communicated via email to all Emergency Department (ED) medical staff the requirement that all patients attending the ED must undergo a medical review prior to any referral to mental health services.
This process is subject to monthly audit, and the most recent audit demonstrated 100% compliance, with all patients referred to mental health services having received a documented medical review. This audit is part of an ongoing quality assurance initiative and is reported through the Audit and Effectiveness Forum to ensure sustained oversight and continuous improvement.
Finally, I hope this response provides assurance that the Trust has taken meaningful steps to address the concerns raised and remains committed to learning and improving patient safety.
Regulation 28 – Report to Prevent Future Deaths: Ms Emily Hewerdine
I write to you with respect to the Regulation 28 Report issued on the 28 July 2025 to Chief Executive of Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust following the inquest into the death of Ms Emily Hewerdine.
The report was received by the Chief Executive’s office and forwarded to me in order to provide a response.
Each concern is outlined in bold, followed by the Trust’s response:
Firstly, I would like to take this opportunity to express the Trust’s sincere condolences to the family and friends of Ms Emily Hewerdine.
Concern: That patients on the wards at Bassetlaw District General Hospital (BDGH) may receive inadequate assessments of hydration status, with inaccurate and incomplete fluid balance chart documentation.
Under the Patient Safety Incident Response Framework (PSIRF), one of the Trust’s identified local priorities in 2024 was the recognition and management of the deteriorating patient. In response, a Trust-wide Safety Improvement Plan was developed, which includes targeted actions to improve fluid balance chart accuracy and hydration assessments.
Progress against this plan is monitored through the Trust’s governance structures, specifically the Patient Safety Assurance Group, chaired by the Chief Nurse and attended by the Executive Medical Director.
Following Ms Hewerdine’s case, the Trust commissioned a Patient Safety Incident Investigation (PSII) to identify learning and implement improvements. Measures introduced include:
• Use of Tendable, the Trust’s audit and quality improvement application, enabling weekly audits and monthly oversight by the Matron. Non-compliance triggers ward- level action plans.
• Transition to electronic fluid balance charting, enhancing accuracy and enabling real- time oversight.
• Ongoing education and training initiatives led by the Division of Medicine in collaboration with the Quality Improvement team.
• Implementation of an Acute Kidney Injury (AKI) Care Bundle within the electronic patient record system in pilot areas. This includes prompts for fluid balance chart initiation and completion. Early evaluation indicates improved monitoring, with full Trust-wide rollout planned for February 2026.
Concern: That nursing assessments, particularly in very vulnerable patients, may fail to identify deterioration, preventing timely escalation for medical review.
In 2023–24, the Trust introduced the Care Accreditation and Recognition for Excellence (CARE) Framework, providing structured, objective evaluations of service quality. This framework supports continuous improvement and identifies areas requiring development. The Chief Nurse Oversight Framework complements this by enabling monthly reviews to detect quality triggers. This is a proactive process designed to identify areas requiring escalation and support early.
In 2024–25, nutrition-related indicators were incorporated into the CARE Framework, including:
• Compliance with MUST score assessments.
• Attendance of Link Nurses at quarterly training sessions.
• Peer review visits focused on food intake and mealtime practices.
The Trust also conducts regular Nutrition and Mealtime Peer Reviews, with findings reported to the Nutrition Action Group, which in turn reports to the Patient Safety Assurance Group. This ensures cross-divisional oversight and alignment with the Safety Improvement Plan.
To enhance communication and safety culture:
• Verbal handover processes during shift changes have been strengthened.
• Safety Huddles have been launched Trust-wide and embedded at BDGH. These evidence-based initiatives support real-time identification and escalation of safety concerns. For example, a recent huddle identified a patient declining all oral intake, prompting immediate clinical review.
Additionally, the Division of Medicine are hosting a Gastroenterology Masterclass on 7 October 2025, focusing on multi-disciplinary training. A key component was the importance of comprehensive nutrition and hydration assessments for patients with Inflammatory Bowel Disease (IBD), including accurate fluid input/output monitoring.
Concern: That patients attending the Emergency Department at Bassetlaw DGH may not receive a clinical assessment prior to referral for mental health evaluation or prior to discharge. Divisional Director, has formally communicated via email to all Emergency Department (ED) medical staff the requirement that all patients attending the ED must undergo a medical review prior to any referral to mental health services.
This process is subject to monthly audit, and the most recent audit demonstrated 100% compliance, with all patients referred to mental health services having received a documented medical review. This audit is part of an ongoing quality assurance initiative and is reported through the Audit and Effectiveness Forum to ensure sustained oversight and continuous improvement.
Finally, I hope this response provides assurance that the Trust has taken meaningful steps to address the concerns raised and remains committed to learning and improving patient safety.
Sent To
Response Status
Linked responses
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56-Day Deadline
13 Oct 2025
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 8.5.24, I commenced an investigation into the death of 18/8/2025
The investigation concluded at the end of the inquest on the 28th July 2025
The conclusion of the inquest was a Narrative as follows:
Emily had Crohn’s disease, a serious inflammatory bowel condition that affected Emily’s physical and mental health significantly. She had all necessary and appropriate treatment for this condition, but sadly required a sub-total colectomy and end ileostomy on 19.4.24, as her condition was not improving with full medical treatment. Whilst she was well enough post operatively for discharge on 24.4.24, she was not eating and drinking well. She then developed a steroid-induced psychosis, from necessary steroid treatment. On 27.4.24 she was admitted to Bassetlaw DGH with poor eating and drinking, generalised weakness, and confusion and agitation. A DOLS order was put in place on 30.4.24 Over this final admission she developed an ileus with sub-acute small bowel obstruction by 3.5.24, that was not recognised. She developed Acute Kidney Injury Stage 3 secondary to dehydration, which was not recognised. She developed aspiration pneumonitis from vomiting. The vomiting was not recognised to be indicative of an ileus with sub-acute bowel obstruction. This lack of recognition of her serious clinical deterioration by 3.5.24, led to a lack of necessary investigations, (that of repeat blood tests, and a CT scan of her abdomen), and therefore lack of necessary treatment of the dehydration and bowel issues present on that day. Emily further deteriorated over the 4th and 5th May with aspiration, evolving dehydration and acute kidney injury, and with untreated bowel blockage leading to continued vomiting, and to a cardiac arrest on the morning of 6.5.24. By this time she had severe aspiration pneumonitis and then developed multi organ failure from which she could not recover. Had necessary treatment for the bowel blockage and evolving dehydration, been provided on 3.5.24 as it should have been, on balance Emily would not have died on 6.5.24.
Emily’s death was contributed to by neglect
The investigation concluded at the end of the inquest on the 28th July 2025
The conclusion of the inquest was a Narrative as follows:
Emily had Crohn’s disease, a serious inflammatory bowel condition that affected Emily’s physical and mental health significantly. She had all necessary and appropriate treatment for this condition, but sadly required a sub-total colectomy and end ileostomy on 19.4.24, as her condition was not improving with full medical treatment. Whilst she was well enough post operatively for discharge on 24.4.24, she was not eating and drinking well. She then developed a steroid-induced psychosis, from necessary steroid treatment. On 27.4.24 she was admitted to Bassetlaw DGH with poor eating and drinking, generalised weakness, and confusion and agitation. A DOLS order was put in place on 30.4.24 Over this final admission she developed an ileus with sub-acute small bowel obstruction by 3.5.24, that was not recognised. She developed Acute Kidney Injury Stage 3 secondary to dehydration, which was not recognised. She developed aspiration pneumonitis from vomiting. The vomiting was not recognised to be indicative of an ileus with sub-acute bowel obstruction. This lack of recognition of her serious clinical deterioration by 3.5.24, led to a lack of necessary investigations, (that of repeat blood tests, and a CT scan of her abdomen), and therefore lack of necessary treatment of the dehydration and bowel issues present on that day. Emily further deteriorated over the 4th and 5th May with aspiration, evolving dehydration and acute kidney injury, and with untreated bowel blockage leading to continued vomiting, and to a cardiac arrest on the morning of 6.5.24. By this time she had severe aspiration pneumonitis and then developed multi organ failure from which she could not recover. Had necessary treatment for the bowel blockage and evolving dehydration, been provided on 3.5.24 as it should have been, on balance Emily would not have died on 6.5.24.
Emily’s death was contributed to by neglect
Circumstances of the Death
Emily died on 6.5.24, at Bassetlaw DGH. During her final admission, following bowel surgery for Crohn’s disease on 19.4.24, she had unrecognised dehydration leading to AKI stage 3 by the day of her death. She had unrecognised ileus and sub-acute small bowel obstruction, that led to bile stained vomiting over the four days prior to her collapse, and cardiac arrest on the morning of 6.5.24. The vomiting led to aspiration, and to aspiration pneumonitis, as Emily was in a weakened state from dehydration. Her weakened state was also caused by prolonged malnutrition, The malnutrition was secondary to her underlying disease process, that of Crohn’s disease, the recent bowel surgery, and her prolonged poor oral intake. The following significant issues of care during her final admission, have made a more than minimal, negligible or trivial contribution to her death on balance.
• The lack of assessment of fluid balance from admission on 28.4.24 onwards
• The lack of adequate clinical assessment of hydration status from admission, but particularly from 2.5.24 onwards
• The lack of accurate recording of vomiting, from 2.5.24 onwards
• The lack of repeat blood teats from 2.5.24 onwards
• The lack of recognition of the general deterioration in Emily’s clinical state, with increasing weakness, and falls
• The lack of consideration of likely physical causes for her confusion, and general presentation, that were evolving from admission onwards, but were clearly present from 3.5.24 onwards
• The lack of a CT scan of her abdomen on 3.5.24
• The lack of attention and listening to the family concerns, raised throughout her admission but particularly from 2.5.24 onwards
• The lack of assessment of fluid balance from admission on 28.4.24 onwards
• The lack of adequate clinical assessment of hydration status from admission, but particularly from 2.5.24 onwards
• The lack of accurate recording of vomiting, from 2.5.24 onwards
• The lack of repeat blood teats from 2.5.24 onwards
• The lack of recognition of the general deterioration in Emily’s clinical state, with increasing weakness, and falls
• The lack of consideration of likely physical causes for her confusion, and general presentation, that were evolving from admission onwards, but were clearly present from 3.5.24 onwards
• The lack of a CT scan of her abdomen on 3.5.24
• The lack of attention and listening to the family concerns, raised throughout her admission but particularly from 2.5.24 onwards
Copies Sent To
2. The Nottinghamshire Healthcare NHS Foundation Trust
Inquest Conclusion
Emily had Crohn’s disease, a serious inflammatory bowel condition that affected Emily’s physical and mental health significantly. She had all necessary and appropriate treatment for this condition, but sadly required a sub-total colectomy and end ileostomy on 19.4.24, as her condition was not improving with full medical treatment. Whilst she was well enough post operatively for discharge on 24.4.24, she was not eating and drinking well. She then developed a steroid-induced psychosis, from necessary steroid treatment. On 27.4.24 she was admitted to Bassetlaw DGH with poor eating and drinking, generalised weakness, and confusion and agitation. A DOLS order was put in place on 30.4.24 Over this final admission she developed an ileus with sub-acute small bowel obstruction by 3.5.24, that was not recognised. She developed Acute Kidney Injury Stage 3 secondary to dehydration, which was not recognised. She developed aspiration pneumonitis from vomiting. The vomiting was not recognised to be indicative of an ileus with sub-acute bowel obstruction. This lack of recognition of her serious clinical deterioration by 3.5.24, led to a lack of necessary investigations, (that of repeat blood tests, and a CT scan of her abdomen), and therefore lack of necessary treatment of the dehydration and bowel issues present on that day. Emily further deteriorated over the 4th and 5th May with aspiration, evolving dehydration and acute kidney injury, and with untreated bowel blockage leading to continued vomiting, and to a cardiac arrest on the morning of 6.5.24. By this time she had severe aspiration pneumonitis and then developed multi organ failure from which she could not recover. Had necessary treatment for the bowel blockage and evolving dehydration, been provided on 3.5.24 as it should have been, on balance Emily would not have died on 6.5.24.
Emily’s death was contributed to by neglect
Emily’s death was contributed to by neglect
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.