June Findlay

Frimley Park Hospital 
Portsmouth Road 
Frimley 
Surrey 
GU16 7UJ 

3rd February 2026 

HM Coroner Mr Robert Simpson 
Assistant Coroner for Berkshire 
Berkshire Coroners’ Office 
Reading Town Hall  
Blagrave Street  
Reading 
RG1 1QH 

Dear Mr Simpson 

REF: YOUR REGULATION 28 REPORT TO PREVENT FUTURE DEATHS (PFD) DATED 27 
NOVEMBER 2025 

I write further and in response to the Regulation 28 Report received on 27th November 2025, following 
the sad death of June Violet Findlay on 11th December 2024. My deepest sympathies go out to Mrs 
Findlay’s family and those who knew her.  

I am grateful for your thorough inquest into Mrs Findlay’s death. I would like to take this opportunity 
to reassure you that patient safety is taken very seriously by the Trust, and the Trust is committed to 
review and reflect on current practices to identify areas of improvement. I have carefully considered 
your  observations,  and  the  recommendations  raised  in  your  Regulation  28  Report  to  ensure  that 
patients receive the best quality care at the Trust and that future deaths are prevented.  

Summary of Coroner’s Concerns 

The concerns identified relate to: 

1. Recognition of malnutrition risk despite MUST assessments. 

2. Inconsistent use of care planning tools. 

3. Inadequate monitoring and recording of nutritional interventions. 

4. Auditing processes failing to identify repeated documentation gaps. 

The Trust recognises the serious nature of this PFD and is committed to the improvement work. This 
will be led by the Deputy Chief Nurse who will report to the Chief of Nursing and Midwifery. A new 
Nutrition and Hydration Safety Steering Group (NHSSG) will be accountable for the delivery of the 
actions on the detailed action plan with specific timeframes and owners of actions. 

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 Actions Taken and Planned 

Leadership and Accountability: 

1. The concerns raised in this PFD report have been shared and discussed with the Chief Executive and 
all the Executive Directors of the Board. 

2. The Trust recognises the importance of nutrition and hydration, and it is a quality priority for the 
Trust. 

3. The response to the PFD and the detailed Trust wide Nutrition and Hydration Improvement Action 
Plan is being monitored by the new NHSSG and the Quality Assurance Committee, which is a formal 
Sub Committee of the Trust Board. The NHSSF is a new group which will be attended by Senior Nurses, 
Dieticians and representatives from the Multidisciplinary Team (MDT) across the organisation. They 
will be monthly. The action plan will have timescales and owners for every action required which will 
be closely monitored by this group. 

4.  Divisional  Directors  of  Nursing  (DDONS)  within  the  new  Divisional  Structure  will  be  required  to 
provide assurance to the Chief of Nursing and Midwifery that the nutrition and hydration needs of 
patients cared for in their division are being assessed and consistently met and accurately recorded. 

Nutritional and Hydration Safety Steering Group: 

1. A new Nutritional and Hydration Safety Steering Group (NHSSG) was established on the 29.01.26. 
This is chaired by a Deputy Chief Nurse. The Key Performance Indicators (KPI's) related to nutrition 
and hydration will be monitored at this meeting. The NHSSG will have the authority to commission 
specific quality improvement groups as required. 

2.  All  clinical  areas  including  ward,  Emergency  Department  and  other  outpatient  areas  to  have 
nutrition link nurses identified who will support the implementation of best practice in clinical areas. 
They will have a clearly defined role with the nurses completing an education programme. 

3. A thorough review/map of all the education programmes/study days that are provided for both 
registered nurses and healthcare support workers is underway. The aim is to ensure that the training 
we are providing all staff is fit for purpose. The new education programme will address the following 
key  concerns:  documentation  to  ensure  accurate  recording  of  food  consumption,  protected 
mealtimes, tray colours and ensuring the patient receives the correct diet for example soft, and when 
supplements should be  given. All staff will be  given the  updated training and compliance  for each 
clinical area will be monitored by the NHSSG. 

4. Protected Mealtimes champions to be identified for each ward. The role of these champions is to 
ensure that patients are not disturbed or distracted during mealtimes. For example, mealtimes are 
not disturbed by visits to patients from the  multidisciplinary team. Eating their meal is prioritised. 
Specific  training  will  be  provided  to  enable  them  to  support  and  monitor  the  Standard  Operating 
Process that is in place. 

5. Review of how Food & Fluid intake can be documented on Epic (Trust Electronic Patient Record) - 
the daily care flowsheets have been amended to allow for nutritional intake  to be  documented in 
more detail. Safety message and electronic patient record (EPR) bulletins have gone out to clinical 
staff. 

6.  During  February  and  March,  the  Clinical  Education  team  and  Dietitians  will  launch  the  new 
Education Roadshows to raise awareness and support the clinical teams on the wards. 

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 7. The  Trust Food and Drink  Strategy for 2026 to 2030 will be  launched in March 26 by  the  Trust 
Facilities Team. All NHS organisations should maintain a food and drink strategy viewed as a living 
document. It captures how the organisation addresses safe delivery of nutritious and quality food and 
drink for patients; how healthier food and the right environment for staff and visitors are provided; 
and embeds sustainable practices in its service, such as buying food more sustainably and wasting less. 

Outcomes  should  be  detailed  and  measured,  allowing  the  organisation  to  demonstrate  how  it  is 
meeting required standards. This strategy is the blueprint for how the organisation values food and 
drink as medicine; it will form part of the annual returns required by NHS organisations to evidence 
compliance with the Food and Drink Standards. 

New initiative for the Trust to Focus on weight loss. 

1. Implement a new system to flag patients with a concerning weight loss which triggers a swarm 
huddle. A swarm huddle is designed to start as soon as possible after a patient safety incident occurs 
so in this case significant weight loss is identified. The purpose of the swarm-based huddle is to identify 
learning  from  patient  safety  incidents;  this  is  in  line  with  the  National  Patients  Safety  Framework 
(PSIRF). Immediately after an incident is identified the multidisciplinary staff ‘swarm’ to the ward to 
quickly analyse what happened and how it happened and decide what needs to be done to reduce 
risk. Swarms enable insights and reflections to be quickly sought and generate prompt learning. It will 
be expected that the swarm is attended by the Ward Matron and a member of the Patient Safety 
Team. The swarm huddle will then formulate an individualised care plan for the patient which will be 
monitored for compliance by the Ward Manager and Ward Matron. The implementation of this action 
will be a priority for the NHSSG and implemented within the next 3 months. 

2. Develop a Standard Operating Procedure (SOP) for the identification, management and escalation 
of weight loss. 

3. All patients who are identified with significant weight loss in line with the SOP will be escalated to 
the  Ward Matron who will ensure  that a full swarm review including dieticians is undertaken and 
appropriate actions are taken and clearly documented. 

Ongoing work streams 

Harm Free Care - A trust campaign was launched in July 2025 to support a focus on 4 key areas relating 
to improving patient safety. This included improving nutritional care for patients to ensure they are 
assessed for nutritional status and risk of malnutrition using the malnutrition universal screening tool 
(MUST). If they are malnourished or at risk, interventions will be implemented to ensure that their 
status is improved as much as possible. 

The Harm Free Care launch offered an opportunity to provide refresher training to all clinical staff. 
Over a period of 3 months bite size training sessions were commenced which included demonstrations 
on how to complete risk assessments and initiate appropriate care planning on Epic. All Registered 
Nurses can access the training via micro soft teams, and this will be monitored by the Ward Managers 
and compliance reported at the NHSSG. 

The clinical education, Epic training and quality teams visited all wards to offer training and support. 
A trust wide communication plan was also implemented to raise awareness of the Harm Free Care 
Programme. 

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 There was a refresh of Protected Mealtimes as part of the Harm Free Care Programme launch. 

Training has commenced to refresh ward hosts awareness and responsibilities in relation to the colour 
tray system to ensure patients on a red or yellow tray do not have these removed until a registered 
nurse/healthcare support worker has documented intake. 

Audit – There will an altered focus on the audit to provide assurance that patients are adequately fed 
according to their need and that any significant weight loss is appropriately escalated to the Ward 
Matron  to  ensure  that  high  risk  patients  are  highlighted  and  appropriate  action  is  taken  and 
documented in line with the new weight loss SOP. 

Update the audit programme in July 2025 to the 'Harm Free Care' audit programme this is an ongoing 
audit. There is now a specific question in the audit that relates to food charts being completed over 
the  last  24  hours.  The  audit  is  completed  once  a  month  in  all  adult  inpatient  areas.  The  aim  is 
monitoring  the  effectiveness  of  the  education  programme  and  changes  to  Epic  and  the  way  food 
intake is recorded. The numbers of patients audited between July 25, and November 25 is 1,528. 

A  monthly  observational  audit  of  protected  mealtimes  was  also  launched  in  July  2025  to  further 
support the implementation of the trust Protected Mealtimes (including coloured tray guidelines). A 
training programme on 'how' to audit' with a guideline was also produced to aid improved data quality. 
The audit looks at how effective the protected mealtime is on the ward for example are the patients 
ready  to  receive  their  meal  having  completed  their  hand  hygiene  and  are  they  assisted  if  this  is 
required. Matrons and Senior Sisters are required to conduct the audits. Audit results for Harm Free 
Care is now presented at ward sisters, matrons, heads of nursing meetings and the NHSSG. The results 
are also published on the Trust intranet for each individual ward area. 

Further Action 

A  formal  process  will  be  agreed  and  demonstrated  in  a  standard  operating  procedure  to  ensure 
improved oversight of Harm Free Care audit results. This is to ensure that the audit results are seen 
by  the  Divisional  Leadership  Teams  and  are  then  discussed  at  the  appropriate  forums  with 
improvements and interventions agreed and monitored within the Divisions. 

A ward league table will be produced monthly by the Quality Team showing the audit results. These 
will be sent to the Divisional Director of Nursing to address any concerns 

I hope that my response highlights the steps that the Trust has and will continue to take to improve 
the patient safety and in particular nutrition at the Trust. An improvement plan based on learning 
from this inquest, to include the actions above, will be created and actioned with monitoring by the 
appropriate clinical governance teams within the Trust. 

The Trust appreciates your thorough investigation and challenge, both of which are essential so that 
the Trust can continue to learn lessons and take steps to improve patient safety and the quality of 
care  we  provide  our  patients.  As  ever,  my  thoughts  remain  with  Mrs  Findlay  family  and  all  those 
affected by her very sad death. 

Yours sincerely 

    Chief Executive 

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