Alan Hunter

Stepping Hill Hospital 
Poplar Grove 
Stockport 
SK2 7JE 

Email address:  

Telephone:  

Friday 17 December 2021 

Dear Ms Mutch,  

Re: Regulation 28: Report to Prevent Future Deaths  

I am writing following the inquest of the late Mr Alan Harry Hunter that concluded on 13 September 
2021. I am sorry that you found cause to issue Stockport NHS Trust with a Report to Prevent Future 
Deaths, issued to us on 25 October 2021. Please be assured that the matters of concern are of the 
upmost  priority  to  us;    we  would  like  to  provide  you  with  assurance  that  actions  have  been  taken 
since the time of Mr Hunter’s death to improve the care we provide to patients.  

Matters of Concern: 

The  inquest  heard  that  the  quality  of  documentation  relating  to  Mr  Hunter  was  poor 
particularly  in  relation  to  monitoring  his diet  and  weight. The  BMI  was  incorrectly  calculated 
on  admission  and  this  was  not  identified  subsequently.  As  a  consequence  his  MUST  score 
was  inaccurate  and  his  level  of  risk  due  to  his  weight  and  poor  nutritional  status  was  not 
correctly understood. The NICE guidance relating to monitoring weight was not followed and 
this was not recognised by ward managers.  

I  would  like  to  provide  assurance  that  prior  to  Mr  Hunter’s  inquest,  improvement  work  related  to 
MUST,  nutrition  and  hydration  had  already  commenced  with  a  number  of  actions  undertaken  to 
improve the care we provide to patients and the way in which we document and evidence that care. 
The  Nutrition  and  Hydration  Steering  Group  takes  place  on  a  monthly  basis  and  is  chaired  by  the 
Deputy Chief Nurse. This Group reports to the Patient Safety Group chaired by the Medical Director 
and has oversight of improvements to nutrition and hydration across the Trust. Reports received by 
the  Group  include  the  training  compliance  position  for  MUST  screening  training  which  is  currently 
reported at 90.76% trust wide, the compliance position for quality metrics standards for nutrition and 
hydration and fluid balance monitoring undertaken by senior nurses. Each clinicalDivision of the Trust 
provides  a  key  issues  and  assurance  report  to  the  Group  on  a  monthly  basis.  MUST  training  is 
mandatory  for  all  nursing  staff  (registered  nurses  and  health  care  assistants)  and  is  required  upon 
induction and refreshed every three years.  

In  March  2021  we  introduced  a  ward  based  electronic  tool  (patientrack  e-observations  platform)  to 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 monitor nutrition  and hydration.  This daily  risk  assessment  uses a  range  of  clinical factors  affecting 
hydration status and provides a RAG status for the patient that informs the nurse how to monitor the 
patient’s hydration.  

In  addition  to  this,  in  April  2021  the  Trust  launched  the  Stockport  Accreditation  and  Recognition 
System  (StARS),  an  accreditation  programme  designed  to  measure  the  quality  of  care  provided 
throughout the Trust. The scheme incorporates key clinical indicators and support standards related 
to  the  CQC  Fundamental  standards,  including  food  and  drink.  The  StARS  framework  includes  14 
inpatient  standards  including  Nutrition  and  Hydration  and  fluid  balance  charts.  The  Trust  has  set  a 
trajectory  to  complete  assessments  of  all  inpatient  areas  (including  reassessment),  four  community 
areas, paediatrics and the Emergency Department by the end of 2021/22. We are on track to meet 
this  trajectory  despite  significant  pressures  across  Trust  services.  Where  services  are  identified  as 
not achieving the required standard then support with a programme for improvement is given.  

A  seven  minute  briefing  document  has  been  developed  related  to  nutrition  and  MUST  assessment 
and  cascaded  to  teams.  The  seven  minute  briefing  format  is  a  standardised  method  of 
communication used at Stockport NHS Trust to provide teams with key information to improve patient 
and staff safety. The Nutrition and MUST seven minute briefing provides an overview of malnutrition, 
MUST assessments and the use of food charts, and the importance of protected mealtimes.  

Following the inquest of Mr Hunter  where concerns were raised regarding monitoring of his diet and 
weight, an incident report was submitted to the Risk Management System (Datix) to ensure that full 
and appropriate lesson learning would be undertaken related to this case. Duty of Candour was also 
completed to ensure that Mr Hunter’s next of kin was aware of the investigation and able to engage 
in  the  investigation  process.  The  investigation  report  has  now  been  finalised  and  this  is  shared 
alongside this letter to provide assurance regarding the completeness of the review.  

Within the investigation report a robust action plan has been provided that gives additional updates 
on the continuation of improvements across the Trust. This includes the identification of Nutrition and 
Hydration Champions across wards, tool box training sessions provided across ward areas between 
July  and  October  2021  covering  MUST,  fluid  balance,  food  charts  and  specialist  referrals  and  the 
development of Nutrition and Hydration Information Boards in ward areas.  

The  action  plan  also  describes  the  audit  processes  now  in  place  to  ensure  oversight  of  the  MUST 
assessment and the completion of food charts. The Quality Assurance Checks completed by Matron 
twice  weekly  include  a  patient  care  section  which  looks  at  completion  of  nutrition  assessment,  that 
the assessment is up to date, and that fluid balance charts are up to date. The documentation section 
of  the  Quality  Assurance  Check  audits  that  the  MUST  assessments  are  completed  to  the  required 
standard  and  that  standards  of  documentation  are  upheld,  for  example  that  all  nursing  entries  are 
legible,  signed,  dated  and  timed.  Alongside  regular  audit,  daily  safety  huddles  with  the  matron  and 
ward managers take place to review any concerns in regard to patients. This holistic review includes 
a  review of any  nutrition and  hydration  concerns.  It  has been agreed  with  the  Divisional Director  of 
Nursing  for  Surgery  that  with  immediate  effect  that  this  will  also  include  a  check  that  weight  of  the 
patient has been completed where appropriate.  

 
 
 
 
 
 
 
 
 Finally  I  would  like  to  confirm  that  in  October  2021,  the  Trust  took  part  in  Malnutrition  Awareness 
Week, with a timetable of activities including MUST audit, drop in sessions with the nutritional nurses 
and a presentation from the speech and language therapy team. 

I  would  like  to  thank  you  for  highlighting  your  concerns  to  us.  I  hope  that  my  response  and  the 
additional information provided gives assurance that we take your concerns very seriously and that 
action has been taken to improve the processes for managing the nutritional and hydration needs of 
our patients. If you require any further clarification with regard to any information provided, please do 
not hesitate to contact me. 

Yours sincerely 

Chief Executive