“(brief summary of matters of concern) Mrs G had been prescribed a high protein drink…”

The coroner’s concerns

(brief summary of matters of concern) Mrs G had been prescribed a high protein drink supplement (Vital 1.5 Kcal) by her GP in March 2022. She was also prescribed furosemide, a diuretic, 40mg daily to assist with fluid retention arising from congestive cardiac failure. Mrs G followed a gluten and dairy fee diet. On 11 August 2022, Mrs G suffered an unwitnessed fall at home suffering a fractured neck of femur and was brought to A&E. She was frail, dehydrated, and acutely confused. On 13 August 2022, Mrs G had a MUST (malnutrition universal screening tool) score of 2 so did not meet the criteria for referral to a dietician. Four weeks later, on 14 September 2022, Mrs G’s MUST score was 3 and the dietician accepted the referral, reviewed Mrs G and offered advice. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Mrs G was also weighed on a regular basis. The SALT team recommended a food level of 5 (minced/moist) and later 6 (bite size). Food intake was recognised as poor. Fluid intake was a delicate balance – too much could cause pulmonary oedema; too little could cause dehydration. Given the importance of accurately monitoring both fluid and food intake in this context, I have the following concerns albeit I did not find that these matters were causative of death in the present case:A) The Ward Sister said in her evidence that “on occasional days, the fluid and diet charts were only partially completed”. B) There was confusion about whether or not Mrs G was gluten and dairy intolerant. A Mental Health Nurse recorded on 31.08.22 “she was eating and drinking poorly as she follows a gluten and dairy free diet and reported the ward only give her lentil casseroles”. However, the Consultant/Orthogeriatric said in his evidence “..she had very poor oral intake and family were insisting she had an allergy to gluten and lactose despite Mrs Griffiths denying this”. C) The family say that the choice of options for those with gluten and dairy intolerance and also requiring bite sized food was very limited, which disproportionately affects the elderly. D) The family say that the fluid and diet charts were not accurate as the family were bringing in food and this was not being recorded. As the charts were inaccurate, this would also have made it more difficult for the dietician to offer meaningful advice.

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, 2026-0106

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