Joan Howard

“The SALT input into [the deceased]'s care was exemplary. She had appropriate assessments and following a visit on the ward the day after her admission appropriate clear posters were placed above [the deceased]'s bed confirming what nutrition she could have. Despite these posters, on two occasions [the deceased] was provided with inappropriate food.”

“The care home from which [the deceased] was admitted had provided appropriate advice about her nutritional requirements which was available to the hospital upon admission but which was not acted upon.”

“the ward gave evidence which confirmed that there are processes in place for the management of specialist nutritional requirements on the ward however in this case these were not appropriately followed by staff. d”

“The Senior Sister on the ward confirmed that she would expect her staff to follow the guidelines issued by the speech and language therapy team and to 5 understand what was meant by level 2 fluids and level 6 food. This was not the case in practice”

“The Senior Sister on the ward confirmed that where someone had capacity and made an unwise choice which contradicted the indication from speech and language therapy, she would expect staff to escalate this to the clinical team to have a discussion with the patient. This was confirmed by the Matron responsible for the presentation of the Serious Incident Investigation at Court however in [the deceased]'s case, if staff were aware that the choice of two sandwiches and a piece of cake were inappropriate for”

“[the deceased] was sent to an outpatient appointment with no thickener for fluids meaning that prior to her deterioration on the 9 April 2019 she had no access to fluids for the duration of her outpatient appointment and waiting.”