Prevention of Future Deaths reports · 2025

Steven Turzynski

Regulation 28 report to prevent future deaths, reference 2025-0492, written 6 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report6 Oct 2025
Reference2025-0492
DeceasedSteven Turzynski
CoronerCaroline Saunders
Coroner areaGwent
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Regulation 28: REPORT TO PREVENT FUTURE DEATHS

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT DEATHS

THIS REPORT IS BEING SENT TO:

1 Chief Executive Of Aneurin Bevan University Health Board
2 Chief Executive Of Velindre University Nhs Trust

1

CORONER

I am Caroline SAUNDERS, Senior Coroner for the coroner area of Gwent

2

CORONER’S LEGAL POWERS

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

3

INVESTIGATION and INQUEST

On 07 August 2024 I commenced an investigation into the death of Steven Paul
TURZYNSKI aged 70. The investigation concluded at the end of the inquest on 25
September 2025.

The conclusion of the inquest was recorded as:

Death from Natural Causes

The medical cause of death was:

1a) Pneumonia
1b) Metastatic Squamous cell Carcinoma of the Lung
2) Oropharyngeal Cancer (treated)

Steven Paul Turzynski died from the effects of lung cancer at the Grange University
Hospital, Llanfrechfa on 29/7/2024.

4

CIRCUMSTANCES OF THE DEATH

Steven Paul Turzynski was a 70-year-old man who had successfully undergone treatment
for oropharyngeal cancer in 2019. The nature of the cancer affected Steven’s ability to eat
and to enjoy food.

In January 2023, Steven was diagnosed with lung cancer. His treatment thereafter further
affected his ability to maintain adequate nutrition.

Steven’s dietetic care was shared between Aneurin Bevan University Health Board and
Velindre University NHS Trust. Steven was under the care of dietitians in both departments
at the same time. However, through the course of his treatment from November 2023 until
his death in August 2024, there was very little communication between the two teams and
no sharing of information or discussion about treatment plans. Steven required ongoing
nutritional support and was on occasion receiving different advice from these two teams.

The poor communication was further hampered by an inability for the respective teams to
access each other’s records.

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

 The inquest was told that adequate nutrition could not be determined merely from
recordings of a person’s weight or their alleged intake, but required an assessment of frailty
and cachexia, matters which needed to be assessed in person.

Throughout this time, Steven had only 2 face to face appointments with members of the
dietetics department

By the time of his death Steven was suffering from significant undernutrition.

5

CORONER’S CONCERNS

During the course of the investigation my inquiries revealed matters giving rise to concern.
In my opinion there is a risk that future deaths could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows:
(brief summary of matters of concern)

Steven Paul Turzynski died from the effects of cancer, which was also responsible for his
nutritional status. However the almost absent communication between the two dietetic
teams and the lack of adequate assessment during the last 12 months of Steven’s life
contributed to his poor nutritional state.

I was informed at the inquest that the need for a face to face appointment is entirely a
matter for the individual dietician. However, this decision making is not governed by
guidelines nor is it monitored and can lead to an over-reliance of telephone assessments.

Adequate nutrition for patients who have cancer is a significant element of their care and
inadequate nutrition can contribute to an early death.

Kindly inform me whether your organisations have taken steps to improve co-working
within disciplines when sharing the care of patients who require hospital and community
dietetic care.

Kindly inform me whether action will be taken so that when care is shared, the respective
teams can access each other’s records.

Kindly inform me whether there are plans for setting guidelines or monitoring the adequacy
of dietetic assessments over the phone, and a minimum standard set for face to face
consultations.

6

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you (and/or
your organisation) have the power to take such action.

7

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by December 01, 2025. I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION

8

I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons

Family And/Or Next Of Kin Of Steven Paul Turzynski

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

 I have also sent it to

Health Inspectorate Wales

who may find it useful or of interest.

I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.

I may also send a copy of your response to any person who I believe may find it useful or
of interest.

The Chief Coroner may publish either or both in a complete or redacted or summary form.
He may send a copy of this report to any person who he believes may find it useful or of
interest.

You may make representations to me, the coroner, at the time of your response about the
release or the publication of your response by the Chief Coroner.

9

Dated: 06/10/2025

Caroline SAUNDERS
Senior Coroner for
Gwent

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

Responses

2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Aneurin Bevan University Health Board (PDF)
Executive Director of Nursing | Gweithredol Cyfarwyddwr Nyrsio 

Private & Confidential 
Caroline Saunders 
Senior Coroner for Gwent 

Dear Ms Saunders 

Thursday, 27 November 2025 

Response to Regulation 28 Report received following the inquest touching on the death of 
Steven Paul Turzynski 

Thank you for your letter and accompanying report, which the Health Board received on 6 October 
2025. This letter provides the Health Board’s formal response to the Regulation 28 Report to prevent 
future deaths following the inquest into the death of Mr Steven Paul Turzynski. 

To  provide  assurance  that  meaningful  and  lasting  improvements  are  being  achieved  across  the 
Health Board, we have implemented a strengthened governance framework dedicated to nutrition 
and  hydration.  This  framework  enhances  organisational  coordination,  ensures  accountability  for 
quality improvement, and embeds systematic oversight within our Quality Management System. 

At its core, the framework consists of a Strategic Nutrition and Hydration Group, supported by two 
operational sub-groups. Each group has clearly defined roles, multi-professional membership, and 
a  direct  reporting  route  from  frontline  practice  to  board  assurance,  ensuring  that  clinical  and 
operational perspectives are aligned. 

The Strategic Group provides senior clinical leadership and organisational assurance. Chaired by 
the  Assistant  Director  for  Allied  Health  Professions  and  Health  Science,  it  includes  senior 
representatives from Nursing, Medicine, Finance, Digital, and Quality & Patient Safety. The inclusion 
of Llais within its membership ensures that the views and experiences of patients and service users 
inform  all  improvement  activity.  Meeting  every  two  months,  the  group  reviews  incident  themes, 
monitors risk registers, and oversees progress against strategic improvement priorities. It also acts 
as  an  expert  reference  group  for  the  wider  organisation  on  all  matters  relating  to  nutrition  and 
hydration safety. 

Two operational groups report into this structure: 

  Food  Standards  Group  –  responsible  for  operational  oversight  of  food  service  delivery, 
dietary  standards and compliance  with  the  All-Wales  Nutrition  and  Catering  Standards  for 

Bwrdd Iechyd Prifysgol Aneurin Bevan 
Pencadlys, Ysbyty Sant Cadog 
Ffordd Y Lodj, Caerllion, Casnewydd NP18 3XQ 

 01633 436 700   

 BwrddIechydPrifysgol   

 BIPAneurinBevan 

Rydym yn croesawu gohebiaeth yn Gymraeg a byddwn yn ymateb yn Gymraeg heb oedi. 
Bwrdd Iechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan. 

Aneurin Bevan University Health Board 
Headquarters, St Cadoc’s Hospital 
Lodge Road, Caerleon, Newport NP18 3XQ 

 01633 436 700   

 AneurinBevanHealthBoard  

 AneurinBevanUHB 

We welcome correspondence in Welsh, and we will respond in Welsh without delay. 
Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board. 

 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 Food and Fluid Provision for Hospital Inpatients. It meets monthly to review incidents, drive 
service improvements, and escalate key issues to the Strategic Group 

  Clinical Standards Group – overseeing clinical practice in relation to nutrition and hydration 
across acute, community, maternity, paediatric and older adult services. The group monitors, 
compliance and leads on risk-assessment processes and ensures that clinical standards are 
applied consistently across all care settings 

This  governance  model  has  already  accelerated  the  delivery  of  targeted  improvements,  such  as 
enhanced nutritional screening, included in our ward accreditation programme, monitoring of fluid 
balance,  strengthened  escalation  processes  for  patients  at  risk  of  malnutrition,  and  improved 
documentation  standards.  These  developments  are  now  being  embedded  into  routine  practice 
through  the  Quality  Management  System,  supporting  a  proactive  and  transparent  approach  to 
preventing avoidable harm. The Health Board has also recently created and successfully appointed 
the  first  Consultant  Dietitian  post  in  Wales  with  a  specific  remit  for  Nutrition  and  Hydration.  This 
senior  clinical  leader  will  embed  Nutrition  and  Hydration  at  the  core  of  our  clinical  care  and 
strategically in our policies and clinical pathways. 

In  summary,  this  framework  provides  the  Health  Board  with  strong  clinical  leadership,  effective 
operational  alignment,  and  meaningful  service-user  involvement  in  the  ongoing  improvement  of 
nutrition and hydration care. It offers a clear mechanism for ensuring that learning from incidents 
leads to sustainable, system-wide change. 

The information below outlines the specific actions undertaken and those in progress to reduce the 
likelihood of similar circumstances arising in the future. These are detailed within the accompanying 
multi-professional improvement plan appended to this letter. 

1. Communication and Information Sharing Between Health Boards 

Assurance Statement 
Aneurin Bevan University Health Board (ABUHB) and Velindre University NHS Trust (VUNHST) 
recognise the coroner’s concern that inadequate communication between each organisations 
dietetic teams contributed to suboptimal nutritional management. Both organisations are 
committed to strengthening the safety and consistency of information exchange for all patients 
whose care is transferred across organisational boundaries. 

Planned / Ongoing Actions 

  Joint Transfer of Care Standard Operating Procedure (SOP): 

A collaborative SOP is being developed between ABUHB and VUHNHST to define clear 
referral, handover, and documentation standards for patients receiving shared dietetic care. 
The SOP will outline required content for transfer summaries, response timeframes, and 
points of professional contact 

  Shared Access to Clinical Records: 

Both organisations are reviewing long term digital interoperability options with potential 
single patient care records, dependant on Digital Health & Care Wales support. In the 
interim, read only access to ABUHB clinical system (CWS) has been granted to VUHNHST 
dieticians and WCP access will be granted to appropriate cohort of ABUHB Dietitians 

 
 
 
 
 
 
 
 
 
   Multidisciplinary Interface Meetings: 

Quarterly meetings will be held between ABUHB and VUHNHST dietetic leads to discuss 
and review any shared oncology cases, clinical incidents, resolve communication issues, 
and identify opportunities for process improvement 

How these actions address the concern 
These steps ensure that dietitians in different hospitals can share information across 
organisational boundaries, understand who is responsible for each patient, and provide consistent 
nutritional advice. Patients will no longer receive conflicting information as both teams will have 
shared visibility and direct contact pathways. Cross site interface meetings will facilitate shared 
learning and information sharing. 

2. Clinical Standards and Governance for Mode of Dietetic Assessment 

Assurance Statement 
The Health Board acknowledges the coroner’s concern regarding the absence of guidance for 
determining when dietetic assessments should be conducted face-to-face versus by telephone. 
The organisation, in collaboration with Velindre, is updating and enhancing existing clinical 
standards to guide assessment practice and ensure equity and quality of nutritional care 

Planned / Ongoing Actions 

  Dietetic Assessment and Consultation Guideline: Development of an operating protocol 
to define clinical criteria for the mode of assessment. This will include consideration of 
disease complexity, nutritional risk, treatment phase, and patient preference. ABUHB 
booking process being adapted to facilitate face to face review as an initial assessment. 

  Decision-Making Tool: Decision-making tool to be introduced, requiring clinicians to 
record their rationale for remote versus in-person assessment in the patient’s notes, 
promoting transparency and auditability 

How these actions address the concern 
Where a patient is unable or unwilling to travel for an in-person review, a face-to-face assessment 
will still be arranged through a home visit or other clinically appropriate alternative setting to 
ensure that frailty, weight loss and nutritional risk are directly assessed. 

3. Monitoring, Audit and Continuous Improvement 

Assurance Statement 
The Health Board is committed to ensuring that the above improvements are sustained through 
regular audit, shared learning, and oversight via established quality governance structures. 

Planned / Ongoing Actions 

  Annual Joint Audit: ABUHB and VUNHST will jointly audit adherence to the Dietetic 

Transfer of Care Standard Operating Procedure and Assessment Protocol, with findings 
reported to each organisation’s Nutrition & Hydration Group and/or Quality & Patient Safety 
assurance group 

 
 
 
 
 
 
 
 
 
 
 
   Exception and Learning Reporting: Any deficiencies or recurrent communication failures 
will be logged through Datix and reviewed at joint governance meetings. Themes and 
learning will be fed into professional development sessions 

  Workplan Integration: Requisite improvement actions will be included within the ABUHB 
Nutrition & Hydration Group workplan, with progress reviewed bi-annually and updates 
shared with VUHNHST governance partners 

  Quality Assurance: Peer review and clinical supervision sessions will be embedded into 

dietetic governance structures within ABUHB, focusing initially on oncology cases   
  Spreading the learning: Dietetics service will present learning from this case at the 

ABUHB patient quality & safety learning and improvement forum 

How these actions address the concern 
A system of disseminating learning from incidents and regular compliance audits will ensure all 
staff follow consistent standards when providing dietetic care, regardless of where they work. 
Lessons learnt from this case will be embedded into professional development and ongoing 
supervision so that improvements are maintained long term 

Governance and monitoring 

In parallel with the joint work undertaken with VUHNHST, ABUHB continues to strengthen its own 
internal  systems  to  ensure  that  exacting  standards  of  nutrition  and  hydration  care  are  delivered 
consistently  across  all  divisions.  Locally,  this  includes  the  development  of  enhanced  digital 
documentation  tools,  strengthened  escalation  frameworks  for  patients  at  nutritional  risk,  and 
teams. 
increased 

learning  within 

supervision 

reflective 

clinical 

and 

use 

of 

At a system level, the Health Board and VUHNHST have committed to working in close partnership 
to maintain and monitor these improvements. Regular joint meetings between both organisations 
will  review  progress  against  the  action  plan,  share  emerging  learning,  and  resolve  any  cross-
boundary issues in real time.  

An annual joint audit of service quality will also be undertaken to evaluate the effectiveness of the 
improvement. 
collaborative  arrangements  and 

further  opportunities 

identify 

for 

to 

Together, these local and joint actions provide assurance that improvements are both organisation-
led  and system-wide, supporting sustained and measurable progress in the  safety and quality of 
dietetic care. 

We accept and are sorry that there were elements of Mr Turzynski’s care that fell below the 
standards we would want and expect for our patients and appreciate how devastating this has 
been for his family and we are committed to ensuring that the circumstances surrounding Mr 
Turzynski’s end of life nutritional care result in meaningful and sustained improvements in 
communication, record-sharing and dietetic care. 

Yours sincerely, 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Prif Weithredwr | Chief Executive 

Enc. Action Plan
Response from Velindre University NHS Trust (PDF)
Pencadlys Ymddiriedolaeth GIG Prifysgol Felindre 
Velindre University NHS Trust Headquarters 
2 Cwrt Charnwood 
Heol Billingsley 
Parc Nantgarw 
Caerdydd/Cardiff 
CF15 7QZ 

Ffôn/Phone: (029) 20196161 
https://velindre.nhs.wales 

28th November 2025 

FAO: Ms. C Saunders 
Gwent Coroners Service 
Livingstone House 
Langstone Business Village 
Langstone Park 
Newport, 
NP18 2LH 

Dear Ms Saunders, 

Re: Regulation 28 Response  

I am writing to provide Velindre University NHS Trust’s formal response to the Regulation 
28 Report issued on the 6th October 2025 following the inquest into the death of Mr. 
Steven Paul Turzynski.  

I would like to start by thanking you for raising these extremely important matters with the 
Trust  and  to  apologise  for  the  failings  identified  through  the  inquest  process.  Velindre 
University NHS Trust both acknowledges and accepts the concerns raised relating to the 
adequacy of nutritional assessment, communication between dietetic teams, and the need 
for  strengthened  standards  for  face-to-face  consultations  for  patients  receiving  cancer 
treatment. We fully recognise the significant role that appropriate nutritional support plays in 
ensuring safe and effective cancer care, and the serious implications when those standards 
are not met. 

The Trust has undertaken a comprehensive review of practice and implemented targeted 

Mae Ymddiriedolaeth GIG Prifysgol Felindre yn hapus i dderbyn gohebiaeth yn y Gymraeg neu’r Saesneg. 
Velindre University NHS Trust is happy to receive communication in Welsh or English. 

 
 
 
 
 
 
 
 
 
 
 
 
 Pencadlys Ymddiriedolaeth GIG Prifysgol Felindre 
Velindre University NHS Trust Headquarters 
2 Cwrt Charnwood 
Heol Billingsley 
Parc Nantgarw 
Caerdydd/Cardiff 
CF15 7QZ 

Ffôn/Phone: (029) 20196161 
https://velindre.nhs.wales 

improvement  actions.  We  continue  to  work  closely  with  Aneurin  Bevan  University  Health 
Board (ABUHB), reflecting the joint nature of this Prevention of Future Deaths (PFD) Report,   
to  ensure  that  safe,  consistent  and  coordinated  dietetics  care  is  provided  across 
organisational boundaries. 

I have attached the Trust’s improvement plan that has been developed in conjunction with 
ABUHB for reference. 

For  ease  of  reading  I  have  detailed  below  the  specific  actions  undertaken  and  those  in 
progress to reduce the likelihood of similar circumstances arising in the future: 

Development & Improvement  

To  ensure  sustained  system-wide 
improvements,  Velindre  Cancer  Service  has 
strengthened  its  governance  arrangements  relating  to  dietetic  care,  including  enhanced 
reporting  mechanisms,  improved  visibility  of  service  risks,  and  increased  oversight  of 
multi-professional clinical standards. We have implemented a series of measures to improve 
co-working  and  communication  between  hospital  and  community  dietetic  services, 
including: 

• A joint communication protocol and Multi-Disciplinary Team checklist to standardise the 
processes for shared care patients 

•  Quarterly  joint  dietetic  meetings  with  ABUHB  to  support  shared  learning  and  early 
escalation of any potential risks or issues 

• Review and confirmation of Upper Gastrointestinal and Head & Neck clinical pathways 

• Development of an interim shared care transfer document until the All-Wales standard is 
formally approved 

Mae Ymddiriedolaeth GIG Prifysgol Felindre yn hapus i dderbyn gohebiaeth yn y Gymraeg neu’r Saesneg. 
Velindre University NHS Trust is happy to receive communication in Welsh or English. 

 
 
 
 
 
 
 
 
 
   
  
 Pencadlys Ymddiriedolaeth GIG Prifysgol Felindre 
Velindre University NHS Trust Headquarters 
2 Cwrt Charnwood 
Heol Billingsley 
Parc Nantgarw 
Caerdydd/Cardiff 
CF15 7QZ 

Ffôn/Phone: (029) 20196161 
https://velindre.nhs.wales 

•  Active  engagement  with  the  Welsh  Dietetic  Leaders  Advisory  Group  (WDLAG)  to 
strengthen cross-boundary referral processes 

The above steps will ensure that dietitians in different hospitals can share information across 
organisational  boundaries,  understand  who  is  responsible  for  each  patient,  and  provide 
consistent nutritional advice. Patients will no longer receive conflicting information as both 
teams will have shared visibility and direct contact pathways. Cross site interface meetings 
will facilitate shared learning and information sharing. 

We also recognised following the inquest the risk of not seeing patients face to face and we 
have developed plans and guidelines to ensure the adequacy of dietetic assessments over 
the phone, and a minimum standard set for face-to-face consultations. The steps we have 
taken  to  date  include  benchmarking  locally,  regionally  and  nationally  to  help  inform  the 
development  of  a  draft  Standard  Operating  Procedure  which,  following  approval,  will  be 
evaluated to ensure that it is embedded into practice.  

Governance and Monitoring  

To provide assurance of ongoing monitoring, evaluation and sustained improvements any 
Improvement  work  is  overseen  through  the  Velindre  Cancer  Service  Quality  &  Safety 
governance  structure.  Progress  is  monitored  via  the  Trust’s  electronic  regulatory  and 
assurance tracker and is reported to the Executive Management Board and Quality, Safety 
and Performance Committee. Monthly joint meetings with ABUHB ensure close alignment 
and shared accountability in relation to our shared improvement actions. 

We have written to Mr Turzynski’s partner to express our sincere apologies that the care 
provided did not meet the standards to which we are committed, and we have offered the 
opportunity to meet with the clinical team. 

I hope that this response provides you with the assurance required that the action we have 
taken is robust enough to prevent future deaths related to dietetic support and provision.  

Mae Ymddiriedolaeth GIG Prifysgol Felindre yn hapus i dderbyn gohebiaeth yn y Gymraeg neu’r Saesneg. 
Velindre University NHS Trust is happy to receive communication in Welsh or English. 

 
 
 
 
 
 
 
 
 Pencadlys Ymddiriedolaeth GIG Prifysgol Felindre 
Velindre University NHS Trust Headquarters 
2 Cwrt Charnwood 
Heol Billingsley 
Parc Nantgarw 
Caerdydd/Cardiff 
CF15 7QZ 

Ffôn/Phone: (029) 20196161 
https://velindre.nhs.wales 

Please do not hesitate to contact me if I can provide any further information. I am truly sorry 
for the issues that have been found and for the impact that these have had on Mr. Turzynski 
and  his  family.  I  hope  to  assure  you  that,  as  a  Trust,  we  are  committed  to  continuously 
striving to improve the care that we provide to all our patients. 

Yours sincerely,  

Prif Weithredwr 

Interim Chief Executive Officer 

Encl: Velindre Cancer Service Dietetic Provision Improvement Plan

Mae Ymddiriedolaeth GIG Prifysgol Felindre yn hapus i dderbyn gohebiaeth yn y Gymraeg neu’r Saesneg. 
Velindre University NHS Trust is happy to receive communication in Welsh or English. 

 
 
 
 
 
 
 
 
 
 
 Dietetic Provision Improvement Plan 

Velindre Cancer Service (VCS) 

Action plan approval:  

Name 
VCS Triumvirate  
Private Trust Quality Safety & 
Performance Committee  
Private Trust Board  

Progress Key:   

Off target - Risk  

Delayed/behind 
schedule 
Not started 

Date  
4/11/25 
13/11/2 

27/11/25 

In progress 

On track 

Completed and 
evidenced 

Dietetic Provision Improvement Plan v0.2 
November 2025 
Regulation 28 

 
 
  
  
  
  
  
  
  
  
 
 
 
 
 Recommendation 1 - To improve co-working within disciplines when sharing the care of 
patients who require hospital and community dietetic care 

Action taken 

Proposed action 

Safety 
action 
owner 
Professional 
Head of 
Nutrition 
and 
Dietetics  

Target 
completion date 

Evidence 

 31/01/2026 

TOR for 
meeting   
Meeting 
notes  
Clinical 
pathways 

To continue 
monthly Dietetic 
professional 
meetings, with 
the next meeting 
arranged for 
17/11/2025 

Meetings undertaken 
on 28/07/2025 and 
06/10/2025 between 
Dietetic departments at 
VCS and ABUHB.  
Upper Gastrointestinal 
and Head & Neck 
clinical pathways 
reviewed, further 
developed and 
confirmed. 
Clinical Pathways have 
been implemented 
across Dietetics at VCS 
and ABUHB.  
To be completed  

1. 

Safety action description 
(SMART) 

 To schedule and conduct 
meetings with ABUHB to 
review and discuss the 
current Head and neck 
and Upper 
Gastrointestinal patient 
pathways, identify gaps 
and/or improvements, and 
agree on next steps for 
pathway optimisation. 

2.  To provide assurance that 
pathways developed 
under safety action #1 are 
completed and embedded 
into practice.  

Dietetic Provision Improvement Plan v0.2 
November 2025 
Regulation 28 

To ensure the 
pathways are 
robust and meet 
the needs of our 
patients, we will 
regularly audit the 
pathways 
implemented. 

Professional 
Head of 
Nutrition 
and 
Dietetics 

To ensure the 
pathways are fully 
embedded into 
practice, the 
target date for 
auditing is 
30/05/2026  

 
 
 
 
 
 This will be 
recorded and 
tracked on our 
internal audit 
governance 
system (AMaT) 
and will be 
reported through 
internal 
governance at 
quality and safety 
board meetings.  
Draft MDT 
checklist will go 
through the 
internal 
ratification 
process and be 
implemented.  
To ensure the 
checklist is robust 
and fit for 
purpose, it is 
necessary to 
undertake an 
audit of the 
checklist. This will 
be recorded and 
tracked on our 

3.  To improve multi-
disciplinary 
communication and 
working processes 
between VCS and ABUHB 
by introducing a shared 
communication 
protocol/checklist and 
establishing when urgent 
joint MDT meetings are 
required. 

Collaboration across 
multi-professional 
teams and both 
organisations to 
develop and implement 
an MDT checklist for 
complex nutritional care 
patients.   

Dietetic Provision Improvement Plan v0.2 
November 2025 
Regulation 28 

Head of 
Therapies  

30/11/2025 

MDT 
checklist  

To ensure the 
checklist is 
embedded the 
target date for 
auditing is 
30/05/2026 

 
 
 internal audit 
governance 
system (AMaT) 
and will be 
reported through 
internal 
governance at 
quality and safety 
board meeting. 
This will be based 
on Quality 
Improvement (QI) 
methodology, 
ensuring the audit 
cycle is 
completed and 
learning is shared 
widely across the 
Trust.  
To utilise local 
transfer form 
between VCS 
and ABUHB  

30/11/2025 

Transfer form  

Professional 
Head of 
Nutrition 
and 
Dietetics 

To utilise the All-
Wales transfer 

30/11/2026 

4.  Formulise an agreed 

method of communication 
for the transfer of patient 
care with all health boards 
leads in Wales – all Wales 
transfer documentation, to 
be used for transfer 
between ABUHB and 
VCS. In the interim to use 
a standardised email 
transfer template. 

A transfer document 
has been developed 
with VCS and ABUHB, 
to be used for shared 
care patients, until the 
All-Wales document 
has been agreed. 
 Discussion of cross 
boundary referral 
concerns and options at 

Dietetic Provision Improvement Plan v0.2 
November 2025 
Regulation 28 

 
 
 
 
 
 
 
 
 
 
 5.  To ensure replication of 
safety action #1,3 &4 
above, across all VCS 
commissioned health 
boards in Wales.  

Head of 
Therapies  

31/03/2026 

the Welsh Dietetic 
Leaders Advisory group 
(WDLAG) to ensure 
comprehensive 
handover of patient role 
07/10/2025 
Meeting date arranged 
between Head of 
Therapies at VCS and 
AHP Clinical Directors 
within local Health 
Boards to address 
pathway review and 
enhanced 
communication 
07/11/2025 

form once agreed 
with WDLAG. 

To start 
replication of 
care, 
standardised 
process and 
protocols to 
ensure the safety 
actions meet 
quality standards 
of care across all 
UHB's 
commissioned to 
provide a service 
to VCS. 

Dietetic Provision Improvement Plan v0.2 
November 2025 
Regulation 28 

 
 
 
 
 
 
 
 
 
 
 Recommendation  2  -  To  improve  accessibility  of  patient  records  across  Trust  and  Health 
Board  

Safety 
action 
owner 
Professional 
Head of 
Nutrition 
and 
Dietetics 

Target 
completion date 

Evidence 

10/10/2025 

Starters 
checklist and 
database of 
CWS access  

Head of 
Therapies 

30/11/2025 

Meeting 
summary  

Safety action description 
(SMART) 

1.  To ensure all Dietitians 
have access to Clinical 
WorkStation (CWS) to 
enable full notes to be 
accessible between VCS 
and ABUHB. 

2.  To schedule formal 

communication with the 
Chief AHP digital advisor 
in Digital Health Care 
Wales (DHCW) and Head 
of Dietetics at ABUHB, to 
review and discuss digital 
systems across Wales, 
identify any gaps or 
improvements, and agree 
on next steps for pathway 
optimisation. 

Action taken 

Proposed action 

We are 100% compliant 
with our Dietitians at 
VCS having access to 
'read only' notes on 
CWS. Accessing this 
system has been 
embedded into day-to-
day practice.  

Meeting held with Chief 
AHP digital advisor, 
VCS and ABUHB 
22/08/2025. 
Shadowing session 
held at VCS with Chief 
AHP digital advisor to 
review current 
processes and systems 
and to make key 
improvements/ 
recommendations 
28/10/2025. 

All new starters 
within the Dietetic 
department will 
have access and 
training to CWS 
which will be 
recorded on our 
training needs 
analysis records 
kept for all staff.  
 Risk to be raised 
with Local health 
Boards, in liaison 
with DHCW, re: 
multiple number 
of digital systems 
in use across 
NHS Wales. 
There is focused 
work ongoing 
regarding the use 
of digital systems 
across Wales, 
and we are 
collaborating with 
DHCW to help 
inform these 
conversations. 

Dietetic Provision Improvement Plan v0.2 
November 2025 
Regulation 28 

 
 
 
 3.  To ensure replication of 
safety action #1 & 2 
above, across all VCS 
commissioned health 
boards in Wales.  

Meeting date arranged 
between Head of 
Therapies at VCS and 
AHP Clinical Directors 
within local Health 
Boards to formalise 
digital access 
07/11/2025 

Head of 
Therapies  

31/03/2026 

Recommendation 3 - To set guidelines/monitoring for dietetic assessments over the phone, 
and a minimum standard set for face-to-face consultations. 

Target 
completion date 

Evidence 

30/11/2025 

SOP 
document  

Safety 
action 
owner 
Professional 
Head of 
Nutrition 
and 
Dietetics 

Safety action description 
(SMART) 

1.  To develop a Standard 

Operating Procedure 
(SOP) to ensure 
standards/ guidance are 
set for Dietitians to 
consider when making 
clinical decision regarding 
telephone review and face 
to face sessions.  

Action taken 

Proposed action 

Benchmarking has 
been undertaken 
locally, regionally, and 
nationally to help inform 
the development of the 
SOP.  

Draft SOP/standards 
have been written  

To finalise the 
Standard 
Operating 
Procedure (SOP) 
for dietetic 
provision of care 
and submit it 
through the 
Velindre Cancer 
Service (VCS) 
internal 
governance 
process for 
approval. 

Dietetic Provision Improvement Plan v0.2 
November 2025 
Regulation 28 

 
 
 
 
 
  
 
 
 
 To implement the 
approved 
Standard 
Operating 
Procedure (SOP) 
for dietetic 
provision of care 
across all 
relevant teams 
within Velindre 
Cancer Service 
(VCS), ensuring 
all staff 
understand and 
adopt the new 
process. 
In order to ensure 
the SOP is robust 
and meets the 
needs of our 
patients, to 
undertake an 
audit of the SOP 
once 
implemented. 
This will be 
recorded and 
tracked on our 
internal audit 
governance 
system (AMaT) 

Professional 
Head of 
Nutrition 
and 
Dietetics 

To ensure the 
SOP is 
embedded the 
target date for 
auditing is 
30/05/2026 

2.  To provide assurance that 
the SOP developed under 
safety action #1 is robust 
and embedded into 
practice. 

Dietetic Provision Improvement Plan v0.2 
November 2025 
Regulation 28 

 
 
 
 and will be 
reported through 
internal 
governance at 
quality and safety 
board meeting. 
This review will 
be based on 
Quality 
Improvement (QI) 
methodology, 
ensuring the audit 
cycle is 
completed and 
learning is shared 
widely across the 
Trust. 

Dietetic Provision Improvement Plan v0.2 
November 2025 
Regulation 28

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