“(brief summary of matters of concern) Steven Paul Turzynski died from the effects of…”

The coroner’s concerns

(brief summary of matters of concern) Steven Paul Turzynski died from the effects of cancer, which was also responsible for his nutritional status. However the almost absent communication between the two dietetic teams and the lack of adequate assessment during the last 12 months of Steven’s life contributed to his poor nutritional state. I was informed at the inquest that the need for a face to face appointment is entirely a matter for the individual dietician. However, this decision  making is not governed by guidelines nor is it monitored and can lead to an over-reliance of telephone assessments. Adequate nutrition for patients who have cancer is a significant element of their care and inadequate nutrition can contribute to an early death. Kindly inform me whether your organisations have taken steps to improve co-working within disciplines when sharing the care of patients who require hospital and community dietetic care. Kindly inform me whether action will be taken so that when care is shared, the respective teams can access each other’s records. Kindly inform me whether there are plans for setting guidelines or monitoring the adequacy of dietetic assessments over the phone, and a minimum standard set for face to face consultations.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0492

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0