Elaine Griffiths

Confidential 

11th February 2026  

Mr Hassan Shah  
Assistant Coroner for Northamptonshire  
The Guildhall  
St Giles Square 
Northampton  
NN1 1DE  

Dear Mr Shah  

Kettering General Hospital NHS Foundation Trust 
Rothwell Road 
Kettering 
Northants 
NN16 8UZ 

Northampton General Hospital 
Cliftonville 
Northampton 
NN1 5BD 

Regulation 28: Report to prevent future deaths re Mrs Elaine Jean Griffiths  

I write in response to the above report issued on 17th December 2025. I would like to firstly express 
my sincere condolences to the family of the late Mrs Griffiths and to acknowledge and apologise for 
the issues related to failures across our nutrition and hydration pathway whilst she was in our care 
at Northampton General Hospital (NGH).   

This response to the Regulation 28 Report is to update you on the actions being taken to address 
the concerns raised.  The following improvement plans and actions have been put in place (or are 
in the process of being embedded across NGH): 

Evidence at inquest described that at times, fluid and diet charts were partially completed 

Since June 2025, the fluid balance charts are available on Nervecentre (NC), which is an electronic 
patient  record  (EPR).  This  has  improved  oversight  of  our  patient  documentation  and  enhanced 
accessibility for consulting teams. Fluid consumption is now electronically calculated and inputted, 
so that consulting teams can easily access the correct quantities.  

As part of our ongoing audit process, staff complete the malnutrition universal screening tool (MUST) 
and compliance with this is audited by our nutrition nurses. This also encompasses reviewing the 
accurate  completion  of  the  patient  food  and  fluid  balance  charts  as  well  as  assessing  whether 
appropriate actions have been followed based on the patient’s MUST score. A key finding from these 
audits is that the transferring of the  fluid balance charts to NC has resulted in an improvement in 
timely and accurate completion of the MUST scores.    

In 2025 our teams updated the Food and Fluid Charts used at NGH and plan to implement these at 
both NGH and Kettering General Hospital (KGH), the two acute hospitals within University Hospitals 
of Northamptonshire NHS Group. The improvements include the addition of prompts to indicate: 

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 •  When a fluid balance chart should commence;  
•  When food and drink is brought in by visitors; 
•  The improved recording of fluid intake following the prescription of oral nutritional supplements. 

MUST  audit  results  are  detailed  below.  These  scores  demonstrate  a  significant  improvement  in 
completion rates of the fluid balance charts since the introduction of the electronic tool, NC. 

We are ensuring that our team of Dietitians and Nutrition Nurses continue to work collaboratively in 
order to develop and deliver monthly training sessions as part of the ongoing Clinical Skills Nursing 
Programme.  These evaluated sessions, in place since January 2026, provide education on essential 
nutrition and hydration principles, including correct completion of documentation such as the food 
and fluid balance charts.  In addition to this, the Trust appointed a Specialist Catering Dietitian in 
March  2025,  and  as  part  of  their  remit,  they  also  deliver  training  for  health  care  assistants  and 
catering staff on nutrition and hydration standards.   

Addressing the confusion as to whether or not Mrs Griffiths was gluten and dairy intolerant.   

It had been documented by a Mental Health Nurse on 31 August 2022 that Mrs Griffiths followed a 
gluten and dairy free diet and noted that the ward gave her only lentil casseroles.  This conflicted 
with the Consultant Ortho-geriatrician’s notes, who documented that Mrs Griffiths had very poor oral 
intake  and  her  family were advising  that  she  had  an  allergy  to  gluten  and  lactose,  despite  Mrs 
Griffiths denying this. 

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 Following the implementation of NC at NGH, we have streamlined processes which has led to the 
improved the recording of this data. This will make the recognition of allergies and intolerances easier 
to identify and more readily available throughout a patient’s care pathway and for future admissions.  
To provide you with further assurance, this detail is presented and discussed during ‘Board Rounds’ 
and therefore also communicated more widely to colleagues involved in a patients care.  

In order  to  support  with improvement  in nutrition  and fluid  management across  the  Trust,  we  are 
exploring the possibility of all ward level staff involved in food distribution, to attain the food safety 
level one training module.  We are currently in the process of reviewing capacity and resource and 
hope to start this process in April 2026.  The aim will be to roll this approach out across both hospitals.      

Mrs  Griffiths’  family  advised  that  the  choice  of  options  for  those  with  gluten  and  dairy 
limited,  which 
those  who require  bite  sized 
intolerance and 
disproportionately affects the elderly cohort of patients.  

food  was very 

for 

In order to meet the National Standards for healthcare food and drink, the Trust appointed a Food 
Services Dietitian in March 2025. Since taking up post, the Dietitian has completed a comprehensive 
analysis of the existing texture of the modified menu to assess nutritional adequacy, allergen safety 
and alignment with patient needs.  Following these reviews, we have established a Multidisciplinary 
Menu  Planning  Group  which  has  brought  together  catering,  dietetics,  nursing  and  patient 
representatives in order to improve the food menu design and to ensure a consistent and inclusive 
availability of suitable options, including those patients with complex dietary requirements.    

The  Trust  is  also  progressing  with  the  procurement  of  a new meal  provider that  will  offer  a  more 
comprehensive range of allergen free meals. We anticipate the full service to be in place by mid-
2026 and in the interim period we are implementing measures to strengthen allergy safe options for 
patients. These measures have included the introduction of a dedicated snack menu that caters for 
patients with both swallowing difficulties and food allergies, as well as an increased range of suitable 
dessert options.  Menus will also be updated to ensure coding for allergens is clearer. 

Mrs  Griffiths’  family  advised  that  the  fluid  and  diet  charts  were  not  accurate  as  they  had 
brought in food that was not being recorded in the records. As the charts were inaccurate, 
this would also have made it more difficult for the dietician to offer meaningful advice. 

In addition to the information provided above, the Trust has now developed an improvement plan 
(action plan attached) with respect to the Food and Fluid Charts.  These include prompts for staff 
to document any food or drink brought in by family/visitors. With the planned improvements to the 
texture modified menu, as well as enhancements across all other menus, our aim is to reduce the 
requirement  for  family/visitors  to  bring  in  food.  Our  Dietitians  are  working  to  ensure  that  clinical 
documentation in relation to food and fluid are completed accurately and in a timely manner, and 
this requirement will be included as part of the Nutrition Nurses and Practice Development team 
training.  Additionally, they have implemented monthly Clinical Skills training and from March 2026, 
there are plans for quarterly MUST training sessions.   

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 I trust that the above information provides assurance on how we have acted on the concerns raised 
within the Regulation 28 Report and our ongoing work to improve the standard of record keeping 
and nutrition and fluid provision for our patients. 

We will write further to Mr Griffiths’ family to apologise and to share details of our learning actions. 

Yours sincerely 

UHN Medical Director 

      Enc: Action plan

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 Action Plan 

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Action No.ActionSpecific Changes to be ImplementedMeasuresAction Owner(s)Planned Completion DateRag Rating: Dark Blue=Signed OffLight Blue=Complete Green= on trackAmber=at riskRed=Off trackComments1Improve completion and accuracy of fluid & diet chartsElectronic fluid balance charts implemented in Nervecentre (NC) to improve accessibility and accuracyMUST completion audited by Nutrition NursesUpdated Food & Fluid Charts to be rolled out across NGH and KGH• % completion of fluid balance charts (target >90%)• MUST compliance rates (target >90%)• Audit outcomes showing reduction in partial/incomplete chartsNutrition and hydration nurses30/06/2026GreenMonitored by the N&H steering group2Improve Staff TrainingMonthly Clinical Skills sessions (in place Jan 2026)Training for HCAs and catering staff delivered by Specialist Catering DietitianFood Safety Level 1 under review for all food‑distribution staff (rollout planned April 2026)• % of ward staff trained (target >85%)• Pre/post training knowledge scores• Reduction in documentation errors related to nutritionNutrition and hydration nurses and dietitians30/06/2026GreenMonitored by the N&H steering group3Improve Recording of Allergies and IntolerancesAllergies recorded consistently in NervecentreAllergy status discussed in daily Board RoundsImproved visibility for clinical and catering teams• % accuracy of allergy status in NC (target >98%)• Number of discrepancies identified in audit• Staff compliance with daily Board Round checksFood and drink dietitian and Nutrition and hydration nurses30/04/2026GreenMonitored by the N&H steering group4Enhance Menu Options for Special DietsMenu analysis completed (2025) for allergens and texture modificationMultidisciplinary Menu Planning Group establishedProcurement of new meal provider offering expanded allergen‑free meals expected by mid‑2026• % of menu items compliant with allergen standards• Patient satisfaction surveys (target >85%)• Reduction in food substitutions due to lack of availabilityFood and drink dietitian  30/06/2026GreenMonitored by the N&H steering group5Improve Documentation of Food Brought by VisitorsUpdated Food & Fluid Charts include prompts for documenting visitor‑provided foodTraining reinforces need for accurate documentationIntroduction of snack menu to reduce reliance on family‑supplied food• % of records documenting visitor-provided food (target >90%)• Reduction in missing data flagged by dietitians• Snack menu uptake metricsFood and drink dietitian and Nutrition and hydration nurses30/04/2026GreenMonitored by the N&H steering group