“Regulation 28 – Before Inquest Document Template Updated 30/07/2020 (brief summary of…”
Dated 27 Nov 2025, from the coroner for Berkshire. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 22 Jan 2026.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated27 Nov 2025
- Deadline22 Jan 2026
- Published on judiciary.uk3 Dec 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Frimley Health NHS Foundation Trust | Response publishedPublished on judiciary.uk in December 2025. |
The coroner’s concerns
Regulation 28 – Before Inquest Document Template Updated 30/07/2020 (brief summary of matters of concern) During the course of Mrs Findlay’s 9-10 days at Frimley Park Hospital she lost at least 5.3kg from an already low weight. She had been assessed as being at high risk of malnutrition shortly after her admission. The care planning records were inconsistent about the interventions required and the level of risk. The record keeping of the actual interventions used on a daily basis to address this risk were absent or largely incomplete and I found that the ward staff did not properly follow the dietician’s advice or the care plans. I am concerned that ward staff are not: 1. Properly recognising the risk of malnutrition to patients, even after completing the MUST2 assessments; 2. Correctly utilising care planning tools to address the risks of malnutrition; 3. Properly monitoring and recording the interventions undertaken to address the risk. This places patients at risk due to unclear information and also means that the hospital cannot learn from mistakes or pick up near misses. No evidence was forthcoming from the Trust at inquest that these shortcomings at Frimley Park Hospital had been acted upon despite the court hearing that 100% of the ward staff had received MUST training and records were audited on a monthly basis. This gives rise to a further concern: 4. The auditing of records does not seem to have identified the repeated failures to record required information.
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, 2025-0601
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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
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