“Although, in the specific circumstances of this case, the delay in the provision of an…”

The coroner’s concerns

– Although, in the specific circumstances of this case, the delay in the provision of an in-person dietetic assessment was not a probable causative factor in Suzanne’s death, the written evidence of a Senior Gastro/Surgical Dietician, admitted under Rule 23, stated: “At present there is no funding in place to provide any dietetic service for weekends or bank holidays. Wards are encouraged and trained to implement the Malnutrition Universal Screening Time ‘MUST’ care plans and utilise enteral feeding starter regimes where appropriate whilst awaiting dietetic input.” (Emphasis added). The further written and oral evidence of the Dietic Professional Lead confirmed that CGH only provides any form of dietetic in-put during weekday working hours ie between 08.00 hours and 17.00 hours, Monday to Friday (excluding Bank Holidays). The Professional Lead further reconfirmed, in terms, that outside of those hours there is simply no specialist dietetic service or cover of 2 any kind at all for patients at CGH. In her evidence she told the inquest that whilst there are, to her knowledge, “different arrangements in different Trusts” to deal with the provision of an ‘out of hours’ service, ranging from on-site clinicians to the availability of on-call advice, no such service of any kind is available at CGH (with proposals advanced by the Dietetic Team for a new business case for funding having not been taken forward). The Professional Lead gave evidence that, in her view, this lack of service was “far from ideal” and further accepted that this will inevitably mean that there will be cases where, as examples, Naso-gastric feeding may not be started as soon as it should be, or that there will occasions when the written generic ‘re-feeding’ guides provided by her Team to the wards may not be appropriately followed (with such failures not being picked up and corrected by her Team). She accepted that in such circumstances this could give rise to the risk of (avoidable future deaths.

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, 2026-0003

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