David Bateman

Chief Nurse & Director of Integrated Professions 
Derriford Hospital 
Derriford Road 
Plymouth 
PL6 8DH  

Date: 14th July 2025 

Private and Confidential 
Mr R. Guy Davies  
Assistant Coroner Cornwall & the Isles of Scilly Coroner’s Area  
H.M. Coroner’s Office 
Pydar House 
Pydar Street  
Truro 
Cornwall  
TR1 2AY 

Dear Mr Davies, 

I am writing in response to your recently issued Regulation 28 Report dated the 22nd of May 2025 
concerning the death of Mr David Bateman. On behalf of University Hospitals Plymouth NHS Trust 
(UHP), we would like to begin by offering our sincere condolences to Mr Bateman’s family for their 
loss. 

Thank you for highlighting the concerns regarding Mr Bateman’s death, we apologise that you have 
had to bring these concerns to our attention. We understand the severity of your concerns and are 
committed to making the necessary improvements that ensures the quality and safety of our services 
and prevents harm to future patients.  

During the course of the inquest the evidence revealed matters giving rise to concern. The matters of 
concern included the following: 

•  The finding of poor nursing care and treatment, particularly relating to ineffective support for 
taking nutrition and insufficient monitoring of weight (during the immediate post-operative 
period, from  the 3rd of September to the 24th of December 2023) that was possibly causative 
of  Dave’s  death  and  the  evidence  of  the  treating  consultant  that  such  poor  care  raised  a 
mortality risk for other patients. 

•  There  was  no  evidence  before  the  court  that  these  concerns  have  been  addressed  and 

remedied.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 A  full  investigation  into  each  of  your  concerns  has  been  undertaken  and  I  have  documented  our 
response below. 

The finding of poor nursing care and treatment, particularly relating to ineffective support for taking 
nutrition and insufficient monitoring of weight (particularly during the immediate post-operative 
period, from  the 3rd of September to the 24th of December 2023) that was possibly causative of 
Dave’s death and the evidence of the treating consultant that such poor care raised a mortality risk 
for other patients. 

Mr  Bateman  was  admitted  to  UHP  on  the  3rd  of  September  2023  for  an  elective  laparoscopic 
panproctocolectomy, ileostomy, and omental packing. He was discharged on 23rd of September 2023 
to a community hospital for rehabilitation. Mr Bateman experienced complications that resulted in 
multiple readmissions to UHP, occurring between the 1st of October 2023, and the 14th of March 2024. 
Initially,  he  was  readmitted  due  to  recurrent  pelvic  collections  requiring  surgical  intervention  and 
antibiotic  therapy.  Subsequently,  he  demonstrated  a  significant  decline  in  engagement  with  staff 
(including the nursing and physiotherapy teams), decreased oral intake leading to weight loss, and 
reduced mobility.  

Mr Bateman was reviewed by the Healthcare of the Elderly and Psychiatry teams in December 2023, 
who initially considered Mr Bateman as having capacity and attributed his decline to a combination of 
prolonged hypoactive delirium and depression, and he was treated accordingly with antidepressants. 
However, during his admission in February 2024, Mr Bateman’s low mood and fluctuating engagement 
with healthcare staff were considered to potentially be related to underlying or mild dementia, which 
may have been exacerbated by the primary surgery and post-operative complications. 

Optimising Mr Bateman’s nutritional intake during the immediate post-operative period would have 
been  essential  in  supporting  his  recovery.  The  UHP  Nutrition  &  Hydration  Policy  outlines  that  a 
malnutrition risk assessment be performed for all adult inpatients within 24 hours of admission, with 
follow-up  assessments  conducted  weekly.  This  assessment  should  include  the  completion  of  the 
Malnutrition Universal Screening Tool (MUST – Appendix 1), which helps identify patients who are 
either malnourished at the time of assessment or at risk of developing malnutrition. The results of the 
risk assessment should guide subsequent care planning, and interventions should be appropriate to 
the level of risk identified. 

A review of Mr Bateman’s clinical records indicates that a MUST was conducted on the 7th of 
September 2023. At that time, Mr Bateman weighed 86kg, and his MUST score was recorded as 0. 
He was rescreened on the 17th of September 2023, during which his weight was documented as 81.1 
kg, representing a 5.9% decrease in weight. The MUST score at this subsequent assessment was 1, 
and a three-day food chart was implemented as Mr Bateman was identified as being at medium risk 
of malnutrition. His nutritional intake was monitored throughout this period, and no further 
concerns were noted prior to his discharge for ongoing rehabilitation at a community hospital on the 
23rd of September 2023. 

Mr  Bateman  was  readmitted  to  UHP  on  the  1st  of  October  2023.  The  investigation  could  not  find 
evidence  indicating that Mr Bateman was weighed or that a  MUST was  conducted until  the 2nd  of 
November 2023, when his weight was recorded as 72.25 kg, representing a 16% weight loss, and his 
MUST score was documented as 4. There is documentation suggesting that a MUST was considered 
on the 1st of October, 16th of October, and the 29th of October 2023. However, the screening could not 
be completed as the nursing team was unable to calculate Mr Bateman’s weight, primarily because 
Mr  Bateman  declined  to  be  weighed.  It  is  not  clear  from  the  review  if  the  risks  associated  with 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 malnutrition and the importance of a weight was explained to Mr Bateman, and it is acknowledged 
that alternative methods, as outlined in Appendix 1, could have  been employed. For example,  the 
team could have considered estimating Mr Bateman’s weight using measurements of mid-upper arm 
circumference (MUAC). 

Once  Mr  Bateman's  weight  loss  was  appreciated,  a  food  chart  was  implemented  and  a  dietician 
referral  was  made  on  the  2nd  of  November  2023,  and  he  was  reviewed  by  the  team on  the 3rd  of 
November 2023. Addition supplements (ensure plus, and fortified milk) were ordered and supplied to 
Mr Bateman to support with his nutritional intake, and a discussion was had with him regarding the 
potential for nasogastric tube feeding should his appetite/nutritional intake not improve. Mr Bateman 
was reviewed again by the dietician on the 7th of November 2023, and Mr Bateman’s nutritional intake 
remained poor, therefore an increase in supplements was made. Mr Bateman was discharged from 
the dietician team, and he was discharged from UHP for on the 11th of November 2023. 

Mr Bateman was later readmitted on the 25th of November 2023, and a MUST was conducted upon 
admission. His weight was recorded as 71kg, representing a 17.5% weight loss with a MUST score of 
0. A subsequent MUST was performed on the 28th of November 2023, indicating a weight of 71.95 kg 
and a MUST score of 0. He was referred to and reviewed by a dietitian on the 30th of November 2023, 
who  recommended  ongoing  monitoring  of  his  nutritional  intake  supported  by  supplements  which 
were ordered and provided.  

Mr Bateman was reassessed on the 12th of December 2023, and his weight was documented as 67kg, 
indicating a 22% weight loss, and his MUST score recorded as 4. He was reviewed again by the dietitian 
on  the  14th  of  December  2023,  and  a  plan  was  implemented  for  nasogastric  tube  placement  to 
facilitate  enteral  feeding.  A  nasogastric  tube  was  inserted  by  the  nursing  team  on  the  same  day, 
although later inadvertently removed resulting in replacement. Mr Bateman’s weight continued to 
fluctuate in the subsequent months despite encouragement to eat and drink, and intermittent enteral 
feeding  and  his  recorded  weight  on  discharge  from  Wolf  ward  on  the  6th  of  February  2024  was 
71.45kg. 

In  conclusion,  the  investigation  determined  that  Mr  Bateman's  post-operative  recovery  was 
protracted  and  complicated  by  multiple  issues  and  complications,  which  significantly  affected  his 
mood  and  mental  health,  leading  to  reduced  engagement  with  care.  While  there  is  evidence  that 
weight measurements and MUST assessments were conducted at various points during his stay, and 
that  food  charts,  supplements,  and  dietician  input  were  considered  and  utilised,  the  frequency  of 
weights and reassessment should have been more prompt at times. Additionally, there were missed 
opportunities to address challenges in completing weight measurements, when Mr Bateman declined 
and  no  evidence  was  found  that  alternative  methods  for  estimating  Mr  Bateman’s  weight  and 
malnutrition risk were considered when a weight could not be gained. This may have supported the 
team to have implemented more timely interventions particularly between the 1st of October 2023 
and the 2nd of November 2023. 

The  Trust  has  reflected  on  these  findings  and  improvements  will  be  made  as  outlined  in  the 
improvement plan in Appendix 2. 

There was no evidence before the court that these concerns have been addressed and remedied. 

The Trust acknowledges that there were two missed opportunities to have identified and addressed 
the  concerns  raised  during  the  inquests.  First  whilst  Mr  Bateman  was  an  inpatient  as  there  were 
frequent  discussions  with  his  family  regarding  their  concerns  about  his  deconditioning,  reduced 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 engagement with care, and poor nutritional intake, and secondly following Mr Bateman’s death when 
the Service Line undertook a structured judgement review. The Trust apologises that these concerns 
were not addressed prior to the inquest and hopes that this response provides some reassurance that 
we have fully explored the concerns raised, and that we are committed to taking the necessary steps 
to improve the safety of our services.  

Should you have any further questions please do not hesitate to contact me. 

Once again, we extend our deepest condolences to Mr Bateman’s family. 

Yours sincerely 

Chief Nursing Officer 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Appendix 1 – MUST screening tool 

 
 
 
 
 
 
 
 
 
 
 
 
 Action Owner  

Director of Nursing  

Target completion date  
31st August 2025 (first 
peer review, with 
ongoing peer reviews to 
become business as 
usual) 

Director of Nursing  

31st August 2025 

Director of Nursing 

31st August 2025 

Appendix 2 – Improvement plan  

Action 

Description 

1 

2 

3 

Regular audit/peer review of 
nutrition care, including the 
frequency and quality of MUST 
assessments should be undertaken 
as part of the peer review 
programme.  

Education session to be provided on 
how to measure the mid-upper arm 
circumference (MUAC) and estimate 
a patient's weight at the Matrons 
Safety Huddle. 

Findings from this investigation, 
including the importance of 
considering alternative 
interventions to estimate a patient's 
weight when a weight cannot be 
acquired to be shared across the 
organisation at the Trusts Harm Free 
care group and Nutritional Steering 
group