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recurance

Margaret Toye

23 Dec 2021 · Coroner Graeme Irvine · East London

The coroner's concerns

  1. 1. lack of nutrition assessment

    “Following admission, Mrs [name redacted] was not assessed for risks of malnutrition by use of the MUST score system. Such an assessment was required for all patients. Erroneously, her notes recorded that she scored Oon the MUST scale which meant that no other staff members began an assessment throughout her admission. It is likely that during admission Mrs [name redacted] would have scored 4 on a MUST assessment, as such a number of mitigations would have been introduced to maximise her nutritional intake.”
  2. 2. inadequate nutrition risk assessment compliance

    “Contemporary audits of compliance of Must scoring on the ward in question demonstrate that one in ten patients are not being assessed for risks of malnutrition.”

Responses

No published response was found on judiciary.uk.

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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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