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recurance

Brian Smith

18 Jun 2026 · Coroner Anna Morris · Manchester South

The coroner's concerns

  1. 1. inadequate nutrition monitoring

    “Prior to his admission on the 24th November, he had a recent prior admission to Tameside General Hospital between the 4th-6th November 2026, where he was treated for urosepsis. It was recognised on this admission that Mr. [name redacted] oral intake and diet were both poor and his MUST (Malnutrition Universal Screening Tool) score was 3 out of 6. I heard evidence that this MUST score should have triggered the use of daily fluid and diet monitoring charts to ensure that Mr [name redacted] was obtaining enough nutrition. At the inquest, there was no evidence that these charts were ever used. Mr [name redacted] was also discharged without being seen by a dietician. I am concerned that a patient who should have had his diet closely monitored and did not and that if this practice continues there is a risk that future deaths could occur unless action is taken”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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