Isabella McCreadie

Frimley Park Hospital 
Portsmouth Road 
Frimley 
Camberley 
GU16 7UJ 

Assistant Coroner for Surrey 
Ms Krestina Hayes  
Woking Coroner’s Court 

By email: 

7 August 2024 

Dear Ms Hayes 

I write further to the inquest into the death of Isabella McCreadie and the PFD Report you 
have written expressing your concerns about risks of future deaths. 

I will take each of your concerns in turn and hope to provide you with reassurance about the 
Trust’s investigation into each of your concerns.  

1.  In evidence I was advised during Mrs McCreadie's stay in hospital her dietetic 
needs  were  not  addressed  as  there  was  insufficient  staffing  in  the  dietitian 
department. I asked the hospital when giving evidence if these issues had been 
addressed and was advised that there were still ongoing. I am concerned that if 
appropriate staffing levels are not put in place, patient's needs will not be met.   

A review is currently being undertaken to look at demand and capacity for the whole of the 
therapy’s  directorate  including  the  dietetics  team  and  a  staffing  proposal  paper  is  being 
compiled. The Trust seeks to reassure you that resources in the dietetics team are being used 
as effectively as possible to ensure patient’s needs are appropriately met and bank work is 
being offered where appropriate. 

Earlier this year, some resource was moved from the Wexham Park Hospital dietetics team to 
Frimley Park Hospital to meet the higher demand in the acute team at Frimley Park Hospital.   

The Trust has engaged with a national benchmarking programme which is being managed by 
the  British  Dietetic  Association  who  feel  that the  current  national  safe  staffing  guidance  for 
dietetics needs to be updated. This is based on the fact that 55% of respondents to the British 
Dietetic Association questionnaire felt there was unsafe staffing within their dietetics team. We 
feel that this illustrates that resourcing for dietetics is a national issue.   

Data  has  been  input  into  the  national  benchmarking  programme  and  the  results  should  be 
shared with us soon.  

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 Where  referrals  to  dietetics  cannot  be  actioned  immediately  due  to  higher  risk  patients 
requiring  their  input,  nursing  staff  are  provided with  safety  netting  advice  from  the  dietetics 
team. Nursing staff are advised of the following first line nutrition support measures that should 
be put in place for patients at medium or high risk of malnutrition:  

“Please  ensure  that  MUST  (Malnutrition  Universal  Screening  Tool)  care  plans  have  been 
implemented (“Malnutrition – high risk” for MUST 2 or more, and “Malnutrition  - medium risk” 
for MUST of 1) 

Patients at medium or high risk of malnutrition (MUST 1 or more) who are able to drink level 
2 fluids or thinner at FPH, should: 

-  be offered the first line oral nutritional supplements (Fortisip Compact Protein) twice 

daily, between meals  

-  have a fortified menu (if able to have a normal diet) 
-  Complete weekly weight and MUST screening 
-  Document  food  and  hydration  intake  (ensure  the  Nutrition  section  on  the  Daily 
Cares/Safety flow sheet is used to document dietary intake). Type yes in the box for 
“Patient flagged at risk of malnutrition” then the relevant boxes will appear to document 
dietary intake.  

-  Patient to be encouraged to eat snacks and to drink between meals (biscuits and milky 

drinks, consider finger food if appropriate) 

-  Red or yellow tray put in place and provide assistance at mealtimes if required 
-  Check  any  symptoms  affecting  food  intake  are  adequately  controlled  e.g.  nausea, 

vomiting 

-  Liaise with clinical team to ensure correct drug treatment e.g. anti-emetics, laxatives 
-  Check that any psychological factors affecting food intake have been highlighted to the 

relevant teams e.g. dementia team 

-  Ensure the patient is on the most appropriate menu for their clinical situation” 

In this case, despite the fact that the dietitian could not complete a full review for the patient 
within the expected 3-4 working days, the dietitian who triaged the referral also implemented 
the first line oral nutritional supplements (Fortisip Compact Protein) on Epic, and therefore the  
nutrition support intervention the patient required was not delayed.  

The Trust has included nutrition improvements as one of its quality priorities for 2024/25 as 
part of its Quality Account. This will be monitored closely and supported in the Trust.  

In April 2024 the Head of Dietetics, Speech and Language Therapy and Podiatry at Frimley 
Health NHS Foundation Trust, who chairs the Fundamental and Better Care council for the 
Trust commenced a quality improvement project focusing on interventions at a ward level to 
prevent malnutrition in our patients. This is due to be completed by March 2025. One of the 
key  aims  of  this  improvement  project  is  to  ensure  patients  at  risk  of  malnutrition  are  being 
given first-line oral nutritional supplements. The possible solutions to be trialled are:  

-  optimising  the  process  in  the  Trust’s  electronic  patient  record  (Epic)  to  ensure  the 

ordering of oral nutritional supplements is clear, efficient and effective; 

-  ensuring the wording on the best practice advisory box on Epic is clear when a patient 

scores medium or high risk of malnutrition;  

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 - 

introduction and roll out of updated online training to ward nurses to enable them to be 
able to order first-line oral nutritional supplements without having to ask for a counter-
signature; 

-  providing  tip  sheets,  posters  and  face-to-face  training  to  ensure  staff  on  wards  are 
aware of who should be ordering oral nutritional supplements and how to order them; 
-  education  for  patients  and  relatives  about  the  importance  of  oral  nutritional 

- 

supplements if a patient is at risk of malnutrition; 
include key messages about oral nutritional supplements in the quarterly key nutrition 
messages from the nutrition steering group; 

-  ensuring  oral  nutritional  supplements  are  visible  on  the  medication  administration 

record; 

These improvements will be reported and monitored at the Nutrition Steering Group in the 
Trust and ultimately by the Quality Assurance Committee. 

2.  During evidence I was advised that a training need had been identified for staff 
regarding pressure sores following the passing of Mrs McCreadie. I have been 
advised in submissions by the hospital that they intend to address this training 
need by identifying eLearning staff can complete. Given in evidence it was 
identified that: 
a) some staff do not know how to support and or handle patients who are in     
pain and refuse to be repositioned; and 

  b) the staff are unaware of the techniques needed to be used to reposition 

patients who have multiple injuries,  

  I do not consider that these can be adequately addressed by eLearning.  

Improvement of the management of pressure ulcers is also one of the Trust Quality priorities 
identified in January 2024. An improvement plan is under way which will be closely monitored 
and reported on at various committees.  

Currently, nursing staff and healthcare support workers receive manual handling training in 
person on induction which provides training on how to reposition patients. This training is 4 
hours  on  induction  for  any  nurse  or  healthcare  support  worker  with  prior  healthcare 
experience  and  6  hours  for  anyone  without  prior  clinical  experience.  Refresher  training  is 
provided online every 3 years. 

As  part  of  both  the  induction  and  refresher  training,  nursing  staff  and  healthcare  support 
workers are trained in how to reposition complex patients with multiple complex injuries. Staff 
are also trained to support patients with the assistance of another staff member whenever 
there  are  issues  such  as  a  patient  being  in  extreme  pain  or  where  they  are  resisting 
repositioning.  

In the coming months the Trust will be introducing a new skin assessment tool (PurposeT). 
This tool is prescriptive with regards to actions that should be taken once a patient’s pressure  
areas  have  been  assessed.  This  is  as  a  result  of  a  new  National  Wound  Care  Strategy 
initiative. There will be training to all nursing staff on how to use this skin assessment tool. 

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 Where patients are refusing repositioning due to pain, all nursing staff and healthcare support 
workers  are  aware  that  analgesia  should  be  offered  as  prescribed.   If  no  analgesia  is 
prescribed, they will seek support and guidance from the relevant specialist team (this may 
be the Pain team, the speciality Dr, on-call Dr, or Night nurse practitioner). 

Every ward has a manual handling champion nurse and healthcare assistant who links in 
with our manual handling trainers and are provided with extra training in order that they can 
support staff with any manual handling concerns which may arise on their ward.   Over the 
next year we will be providing regular face to face education sessions for all staff, regarding 
pressure ulcer prevention.  This will be supported by the lead Tissue Viability Nurse, Practice 
development and wound care specialists. 

The Trust also now has access to a new specialist mattress called a “Dolphin” which can be 
used  in  conjunction  with  a  tilting  bed  frame,  designed  to  manage  patients  who  find 
repositioning extremely painful. The ward staff receive training from the company who supply 
the equipment and the use of the mattress is monitored by the company with weekly visits 
from the supplier’s clinical adviser. There is also access to an electronic help line which can 
be used for any issues which arise. Staff request the dolphin mattress for patients via the 
Trust’s tissue viability nurse. This ensures that these patients, who are at risk of pressure 
injuries due to the fact they find repositioning painful, are also receiving input from the tissue 
viability team.    

3.  During the doctor’s evidence, at inquest, an issue was highlighted regarding 

ordering of fortsips on the hospital computer system, a dietary supplement. An 
order had been made to be started on 10th May to 3rd June twice daily. This was 
not processed. I was advised in evidence by the hospital that the doctor could 
be shown how to release it. However, there is no evidence as to how this error 
could be identified if it should reoccur and a clinician was not aware that the 
order for fortsips was not released on the system.  

Fortisip Compact Protein is a fortified nutritional supplement and as an Advisory Committee 
on Borderline Substances (ACBS) approved product it does not need to be prescribed and as 
such does not need to be released on the Trust’s electronic patient record (Epic) before it can  
be given. Fortisip Compact Protein can be given to a patient by a dietitian, doctor or nurse 
who  has  undergone  relevant  online  training  compiled  by  the  dietetics  team.  First-line  oral 
nutritional  supplements should  be  given  to  any patient  who  is  scored  at  1  or  above  on the 
Malnutrition Universal Screening Tool (MUST) and for whom the supplement is clinically safe.  

We have reviewed Mrs McCreadie’s chart and can confirm that the Fortisip Compact Protein 
was  ordered  by  a  dietitian  on  10  May  2023  at  08:48  and  this  was  auto-released.  Mrs 
McCreadie received the first Fortisip Compact Protein at 09:00 on 10 May 2023. We can see 
however that there were issues with Mrs McCreadie receiving further Fortisip Compact Protein 
supplements during her stay as recommended by the dietitians who triaged Mrs McCreadie’s 
referral on 10th May 2023. 

As a result of this PFD report we have become aware that there is a need for greater 
education to all staff about the Trust’s Adult Oral and Enteral Nutrition Guidelines, and the 
administration of oral nutritional supplements.  

4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The  Trust Guideline  states that:  ‘Patients  who  are  deemed  to  be  at medium  or  high risk  of 
malnutrition should have appropriate first-line oral nutrition support measures initiated at ward-
level. Unless the patient has issues with swallowing, food allergies or is at risk of refeeding 
syndrome,  the  management  guidance  detailed  on  page  two  of  the  Malnutrition  Universal 
Screening tool at the back of the Patient Assessment Booklet should be implemented at ward 
level. This includes….”Provide two Fortisip Compact Protein (FPH)” 

This document is in the process of being updated to reflect the process changes due to the 
implementation of Epic rather than using paper nursing documentation.  

The Trust are investigating whether it is possible to clarify the wording on the best practice 
advisory box in Epic to remind nursing staff of this guideline whenever a Malnutrition Universal 
Screening Tool (MUST) score of 1 or above is inserted into Epic. 

This advisory box would clearly set out that: 

-  All  patients  with  a  MUST  score  of  1  or  more  should  be  given  first  line  nutritional 

supplements twice a day and this should be recorded in their clinical record.  

The advisory box will also remind nursing staff that first line nutritional supplements are not 
medication which needs to be prescribed and can be given to a patient by any nurse who has 
undergone  the  relevant  training.  The  training  is  required  due  to  safety  and  allergy 
contradictions.  

A  small  percentage  of  the  Trust’s  nursing  staff  have  already  undergone  this  training  which 
means  they  can  place  orders  for  Fortisip  Compact  Protein  for  patients  without  requiring  a 
counter signatory and there is a plan to roll out this training to more nursing staff on a rolling 
basis as part of the quality improvement project.    

Ward F6 have taken this issue extremely seriously and they have 100% compliance with the 
training for MUST (malnutrition screening tool).  The nurses on ward F6 have also been 
identified as a priority to receive training to place orders for nutritional supplements.  

4.  At the time of the inquest, I was informed during Mrs McCreadie's stay a number 
of staff were agency staff. I note that the hospital now have more permanent staff 
in  place  on  the  ward  than  when  Mrs  McCreadie  was  on  the  ward.  I  remain 
concerned that agency staff who may still need to be called to assist on the ward 
may  not  have  sufficient  training  on  the  computer  system  used  for  recording 
medical care provided before they are required to do so whilst working on the 
ward. At the inquest there was evidence that insufficient training had been given 
and  therefore  there  were  inconsistencies  in  recording  of  treatment  given  or 
needed.  I  understand  permanent  staff  receive  9  hours  of  training,  whereas 
agency staff may receive only up to 1 hour of training.  

Since October 2023 agency staff have been required to complete one hour of online training 
and 4 hours classroom based Epic training in person before they can work a shift at the Trust.  

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 There is also an assessment at the end of this training to check the user has understood the 
training.  

The Trust has significantly reduced its reliance on agency staff over the last year. In May 2024 
our use of temporary registered nursing staff was down to 10.27%, with only 2.15% of this 
being provided by agency staffing. The remainder of the temporary registered nursing staff 
has been provided by staff employed with the Trust under a bank contract.  

I would also like to reassure you that under the Trust’s temporary staffing policy we have made 
it  very  clear  that  anyone  working  on  the  wards  from  an  agency  will  be  supervised  by  a 
substantive member of staff. This substantive staff member will be available to assist with any 
queries the agency worker may have about recording on a patient’s electronic patient record. 

We have also made ‘My Learning Hub’, (the Trust’s electronic training platform) available to 
all agency staff for any ongoing training which they may require.  

I do hope the above provides reassurance as to the Trust’s ongoing commitment to patient 
safety and continuous service improvement. Please do let me know if any further information 
would be of assistance. 

Yours sincerely 

Chief Executive (Interim) 

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