“Having been made 'nil by mouth', the evidence was that this was well documented in Mr…”

The coroner’s concerns

(1) Having been made 'nil by mouth', the evidence was that this was well documented in Mr Pollyn's records, a sign indicating that he was nil by mouth was placed above his bed, and the board within the ward kitchen was also updated. Despite this, the records indicate that numerous members of nursing staff ensured that water was placed at Mr Pollyn's bedside (which would be standard practice were Mr Pollyn not 'nil by mouth' at the time). While the Trust has updated the relevant policies and sought to disseminate messaging to staff in this regard, I was not reassured that this is solely a matter of policy. The number of staff involved and the period of time over which the issue of unsupervised access to water persisted is potentially suggestive of underlying attitudinal issues. (2) Following on from the above, I heard in evidence that the production of some patient records is a simple tick-box exercise, which is not a concern in itself. However, the impression created by the evidence was that staff members were ticking the box to indicate that water was placed/replaced at the bedside (and following through on that action) because that was the norm for most patients on the ward. This indicates that staff missed the entries in the notes about 'nil by mouth' and the other visual cues that were clear. While I heard that the Trust intends to undertake a review of record keeping, which may not be completed until March 2026, I was given insufficient reassurance that this specific concern is being addressed. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 1st May 2026. I, the coroner, may extend the period.

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, 2026-0134

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