Walter Pollyn

Medway Maritime Hospital 
Windmill Road 
Gillingham 
Kent 
ME7 5NY 

1 May 2026 

Mr Ian Potter 
Area Coroner 
Kent and Medway Coroner’s Court 
Oakwood House 
Oakwood Road 
Maidstone 
ME16 8AE 

Dear Sir, 

Re: Inquest touching on the death of Walter Pollyn - Prevention of Future 
Deaths Regulation report 

We refer to your Prevention of Future Deaths (PFD) report dated 16 December 2026, 
which was sent to the Trust on 6 March 2026, and our response to which is due on 1 
May 2026. 

In advance of responding to the specific concerns raised in the PFD report, I would 
like to express my deep condolences to Mr. Pollyn’s family. On behalf of Medway NHS 
Foundation Trust (‘the Trust’), I want to assure the family and you that the concerns 
have been acknowledged, considered, and acted upon. 

The Trust fully acknowledges the concerns outlined in the PFD report, especially that 
the incident within Mr Pollyn’s care, were not merely a failure of policy adherence, but 
also  reflected  deeper  behavioural,  cultural,  and  system  factors.  Although  relevant 
policies  and  documentation  were  in  place  at  the  time,  they  were  not  consistently 
applied in practice, leading to unsafe care and avoidable risks. 

In response, the Trust has taken a whole system approach, tackling both the specific 
clinical issues related to ‘nil by mouth’ care and the underlying cultural and behavioural 
factors that contributed to those failures. 

Addressing the immediate patient safety risks (‘nil by mouth’ care) 

A detailed Trust-wide ‘nil by mouth’ care improvement action plan has been developed 
and implemented to directly address the potential gaps identified during the Inquest. 
This action plan includes: 

•  Trust-wide, regular ‘nil by mouth’ audits to evaluate adherence to best practice, 
including  staff’s  ability  to  correctly  identify  ‘nil  by  mouth’  patients  and  the 
accuracy of documentation. 

•  Recurrent Trust-wide ‘nil by mouth’ audits for non-procedural patients, initially 
conducted on a quarterly basis while improvements are embedded. A baseline 
audit was completed in March 2026, with a re-audit scheduled for June 2026. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 Audit findings are reviewed by the Fundamental Standards of Care Group (a 
Trust-wide  steering  and  quality  improvement  group  focused  on  enhancing 
fundamental  nursing  care,  including  nutrition  and  hydration,  handover, 
mouthcare, and personal hygiene), and are escalated to the Patient Experience 
Sub-Committee and the Patient Safety and Harm Prevention Sub-Committee. 
•  Targeted education and training to enhance staff understanding of ‘nil by mouth’ 
status, supervised sips of water, and the clinical risks related to aspiration. This 
training  is  provided  face-to-face  alongside  nutrition  and  hydration  education, 
reinforced  through  Harm-Free  Care  study  days,  daily  ward  handovers,  and 
safety huddles. Training compliance is tracked via a central training database. 
•  Clear visual controls and environmental safeguards, including revised bedside 
signage, tracking board flags, and standardised prompts, aim to reduce reliance 
on  memory  or  assumptions.  These  include  standardised  bedside  signage 
stating ‘supervised water only,’ removal of unsupervised water jugs, visible ‘nil 
by  mouth’  indicators  on  electronic  patient  tracking  boards,  and  clear 
documentation prompts. All signage and visual controls are being standardised 
through the Fundamental Standards of Care Group. 
Introduction of a structured ‘nil by mouth’ checklist for non-procedural patients 
to minimise practice variations and ensure key safety steps are not overlooked. 
•  Strengthened  multidisciplinary  communication  to  ensure  all  staff  groups 
involved  in  bedside  care,  including  housekeeping  and  support  staff,  are 
included in safety huddles and handovers. 

• 

•  Digital  system  improvements,  including  exploration  of  automated  electronic 
patient record (EPR) alerts to identify documentation conflicts, such as when 
provision of water is recorded for a patient marked as ‘nil by mouth’. 

Oversight  of  these  actions  is  provided  through  established  governance  structures, 
including  the  Fundamentals  of  Care  Group,  Patient  Experience  Sub  Committee, 
Patient  Safety  and  Harm  Prevention  Sub  Committee,  and  the  Quality  Assurance 
Committee. These bodies operate with defined review cycles (detailed in Group Terms 
of  Reference)  to  ensure  sustainable  improvement  rather  than  relying  on  one-off 
compliance activities. 

Addressing behavioural and cultural contributors 

Crucially, the Trust has recognised that the issues highlighted in this PFD report go 
beyond  processes  and  include  normalised  behaviours,  such  as  task-driven  ‘box 
ticking’, and reliance on routine practice rather than individualised risk assessment. 

To address this, the Trust has integrated the ‘nil by mouth’ improvement work into its 
Cultural  Transformation  Programme,  a  multi-year  Board-led  initiative  aimed  at 
addressing the behavioural, leadership, and attitudinal factors that impact patient and 
staff safety. 

Phase 1 of the Cultural Transformation Programme (completed in September 2025) 
involved  extensive  listening  sessions  (events  where  staff  can  share  their  views, 
wishes,  and  feedback  based  on  their  experience),  workforce  surveys,  and  a  Board 
cultural competence review. This work identified consistent themes including: 

Inconsistent application of policy in practice 

• 
•  Reduced challenge and escalation in pressured environments 

 
 
 
 
 
 •  Normalisation of unsafe workarounds 
•  Fear of speaking up 
•  Variable leadership visibility and accountability. 

Some of these themes are directly related to the issues uncovered in Mr Pollyn’s case. 

These  insights  have  informed  a  series  of  high-impact  actions  already  in  progress, 
including: 

•  Stronger 

leadership  accountability 

frameworks 

that  explicitly  connect 

behaviours to appraisal, recognition, and consequences. 

•  Board-level  oversight  of  culture  and  safety,  with  regular  progress  review 

• 

integrated into formal governance. 
Improved psychological safety and speaking up initiatives, ensuring staff feel 
able to challenge unsafe practice without fear. 

•  Targeted development for middle and senior leaders, recognising their critical 

role in setting behavioural norms at ward level. 

•  Clear  reinforcement  that  patient  safety  outcomes  —  not  task  completion  — 

define success. 

Assurance of sustainability 

The Trust is clear that reassurance cannot be given through policies or training alone. 
Therefore, improvements are being integrated through: 

•  Recurrent audit and measurement 
•  Visible leadership ownership 
• 
•  Cultural metrics alongside clinical performance data 
•  Ongoing  monitoring  through  Patient  Safety  and  Harm  Prevention  Sub-

Integration into existing safety and quality governance 

Committee and Board reporting. 

The  Trust  is  committed  to  ensuring  that  the  lessons  learned  from  this  case  lead  to 
lasting improvements in how patients at high risk of aspiration are identified, protected, 
and cared for — and in how staff are supported, while complacency is challenged and 
addressed. 

Summary 

The  Trust accepts that  Mr  Pollyn’s death  highlighted  unacceptable gaps  in  practice 
and culture. Significant measures have been taken, and are ongoing, to address both 
the specific clinical risks identified by the Coroner and the wider cultural factors that 
allowed  these  risks  to  persist.  On  behalf  of  the  Trust,  I  am  confident  that  these 
combined measures materially reduce the likelihood of a similar death occurring in the 
future, and the organisation remains committed to continuous oversight, learning, and 
improvement. 

We thank the learned Coroner for raising this matter with us and for highlighting an 
opportunity to improve our process. 

 
 
 
 
 
 
 
 
 
 
 
 Yours sincerely,  

Deputy Chief Medical Officer 
Medway NHS Foundation Trust