Management of nutrition and hydration
18. Mr U and his family said staff did not monitor Mrs U’s food and fluid intake or act on their repeated concerns. They said she arrived malnourished, missed meals when taken for investigations, and no food was saved for her afterwards.
19. They also said staff continued to offer supplement drinks even though the family explained these made her sick. They felt the lack of monitoring contributed to her becoming weaker.
20. The Trust said staff screened Mrs U using the MUST on admission, recorded a score of two, and referred her to the dietitian within the required timeframe. The dietetic team triaged the referral as priority three and could not assess her within the 48-hour target period due to service pressures. A second referral on 2 May also recorded a MUST score of two.
21. The Trust accepted the MUST score did not reflect her true nutritional risk and staff should have recognised her deteriorating intake sooner. It also accepted inconsistencies in documentation.
22. This included acknowledgment that food and fluid charts were not consistently completed, and a dietitian’s note was not copied into the paper record. The Trust apologised and has provided training and improved documentation processes.
23. Our nurse adviser said the initial MUST assessment and referral were appropriate. The Trust repeated the MUST screening on 2 May and again recorded a score of two. However, her intake had clearly deteriorated before then.
24. NICE guidance requires weekly reassessment, or sooner if the clinical condition changes. Based on the records, a repeat MUST score taken around 29 April would likely have been higher and indicated increased nutritional risk.
25. Our nurse adviser said food and fluid charts were started but not completed consistently, and this meant staff did not have a clear picture of Mrs U’s nutritional intake. This did not meet the NMC Code, which requires accurate and timely record keeping. The doctors’ notes show staff did raise concerns about her intake verbally, but this was not always recorded in the nursing notes or nutrition charts.
26. Our physician adviser said Mrs U was profoundly unwell throughout her admission with multiple serious health conditions. Her deterioration was driven by underlying illness rather than inadequate nutrition and increased nutritional intake or earlier NG feeding would not have changed the outcome. NG feeding also carries risks and may not have been tolerated given her vomiting.
27. The PHSO Complaint Standards say organisations should listen to concerns, act on them promptly, and keep clear and accurate records to support safe care.
28. Staff did not repeat the MUST screening until 2 May, despite Mrs U’s intake deteriorating earlier in the admission. Together with inconsistent food and fluid charts, this meant staff did not fully recognise her increasing nutritional risk.
29. The Trust has acknowledged these shortcomings, apologised, and taken steps to improve monitoring and documentation (see paragraphs 46–47). Based on our clinical advice, we do not think earlier nutritional intervention would have changed the outcome.
30. Alongside this the Trust has confirmed MUST training is now delivered as an e-learning module and required for all nursing and healthcare assistant roles. Whilst we understand the distress and concerns caused to the family around nutrition, we think the Trust has done enough to put things right.
NG tube timing
31. Mr U and his family said the NG tube should have been placed earlier because Mrs U had eaten very little for several days. They said they received different explanations about whether the dietitians or the ward was responsible for the decision, which made the process feel unclear. They also said the procedure was distressing and felt it should not have been attempted in the final 24 hours of Mrs U’s life.
32. The Trust said the medical team decided to insert the NG tube at 3.19pm on 3 May because they were concerned her poor intake would continue over the weekend. It said dietitians were not involved in this decision and were not on site from that evening onwards. If feeding had started, staff would have used the emergency feeding regimen.
33. The Trust accepted concerns about Mrs U’s intake were not escalated early enough and apologised. It also accepted limited documentation of the clinical reasoning and apologised for the distress caused during the procedure. The Trust said her deterioration later that evening was due to a buildup of acid in her blood and not caused by the NG tube.
34. Our nursing adviser said it is usual to complete investigations and trial oral supplements before considering NG feeding. NG feeding is considered when a person cannot take enough food safely by mouth and has a working digestive system. The timing of the NG tube on 3 May was consistent with standard practice, although the reasoning was not well documented.
35. NG feeding carries risks, including aspiration (food or fluid going into the lungs). Because Mrs U was vomiting, there was a high likelihood she would not tolerate NG feeding, and she may have needed repeated attempts to reinsert the tube. For these reasons, NG feeding could only be considered on a limited number of occasions.
36. Our physician adviser said Mrs U was profoundly unwell throughout her admission with multiple serious health conditions. These included myelodysplastic syndrome (a disorder in which the bone marrow does not produce healthy blood cells), chronic kidney disease, and concerns about a possible underlying cancer.
37. These illnesses can cause blood protein levels to fall, which makes it harder for the body to keep fluid inside the blood vessels. As a result, fluid can build up in the legs, abdomen, and lungs. This happens because of the underlying disease and cannot be corrected simply by eating more or by NG feeding. For this reason, NG feeding would not have changed the course of Mrs U’s illness, and earlier insertion would not have altered the outcome.
38. The decision to insert the NG tube on 3 May was made in the context of a patient who was gravely unwell and approaching the end of life. Our physician adviser said her deterioration later that evening was due to her underlying illness and not caused by the NG tube or the distress of the procedure. Staff did not escalate concerns about her intake early enough, and documentation of the reasoning was limited. The Trust has acknowledged this and apologised.
39. Both advisers said the timing of the NG tube was within acceptable clinical practice and earlier insertion would not have changed the outcome. In light of the steps the Trust has taken and the evidence available, we are satisfied the Trust has addressed the concerns raised and will take no further action.
40. We recognise how distressing this experience was for Mr U and his family, particularly given the circumstances of Mrs U’s final days. Their feelings of confusion and upset are entirely understandable, and our conclusion does not diminish the difficulty of what they went through.
Records and handovers
41. Mr U and his family said staff did not keep reliable records of what Mrs U had eaten or drunk, and this made it difficult for anyone to understand how unwell she was becoming.
42. They said their concerns were not reflected in the notes, and communication between teams was inconsistent. They also described occasions where information about investigations was unclear or contradictory, and felt this showed poor handovers between staff.
43. The Trust accepted there were inconsistencies in the records. Food and fluid charts were started but not completed consistently, and daily care records sometimes conflicted with the charts. A dietitian’s note was entered electronically but not copied into the paper record, meaning it may not have been seen by the clinical team.
44. The Trust acknowledged these issues fell short of expected standards and apologised. It has taken steps to improve documentation, including duplicating dietitian entries in paper notes, providing training, and sharing learning with staff.
45. Our nurse adviser said the inconsistencies in the food and fluid charts did not meet the NMC Code, which requires accurate and timely record keeping. Handovers between departments may not have fully captured concerns about Mrs U’s intake and missed or delayed meals were not always documented. The doctors’ notes recorded concerns more clearly, suggesting staff were escalating issues verbally even when these were not written down in the nursing notes.
46. The documentation and handover fell short of expected standards, particularly in the nursing records. The Trust has acknowledged this, apologised, and taken steps to improve practice.
47. The Trust told us it has taken several steps to improve nutritional monitoring, documentation, and handover. MUST training is now delivered as a mandatory e‑learning module for all nursing and healthcare assistant staff. Compliance with repeat screening and completion of food and fluid charts is monitored through daily audits by ward sisters and monthly audits by matrons, with additional peer review through the ward standards audit.
48. The Trust also introduced a new electronic patient record system in October 2025, which has improved handover processes and ensures dietetic documentation is recorded consistently. It no longer uses paper records. These actions give us confidence that learning from this case has been acted on and we do not think there is more the Trust should do.
49. We understand how frustrating and unsettling it must have been for Mr U and his family when records were inconsistent, and information was unclear. We hope the steps taken provide reassurance that these issues have been recognised and addressed.