Jacqueline Frehe

Trust Management Headquarters
Yeovil District Hospital
Higher Kingston
Yeovil
BA21 4AT

24th June 2026  

Dear Mrs McKinley, 

Re: Regulation 28 Report – Prevention of Future Deaths: Mrs Jacqueline Frehe 

Thank you for your correspondence dated 22 May 2026 regarding your Regulation 28 Report 
issued following the inquest into the death of Mrs Jacqueline Frehe, which concluded on 21 
May 2026.  

First and foremost, I would like to extend my sincere condolences to Mrs Frehe’s family. We 
have carefully considered the findings of the inquest and fully recognise the importance of 
addressing the concerns you have raised to reduce the risk of similar incidents occurring in 
the future.  

Your report identified three key areas of concern: 

Communication  of  nil  by  mouth  (NBM)  status  during  transfer  from  the  Emergency 
Department to inpatient wards 

Documentation and escalation of NBM status communicated by family members 

The  clinical  verification  and  challenge  of  NBM  status  in  patients  presenting  with 
dysphagia and suspected aspiration  

In response, the Trust has developed a comprehensive programme of work to address each 
of these areas. 

1. Standardisation of Emergency Department to Ward Handover 

We have initiated a Trust-wide Quality Improvement programme focused on strengthening 
the handover process between the Emergency Department and receiving areas. This work 
includes  the  development  of  a  revised  SBAR-based  handover  template  (standardised 

 
 
 
 
 
 
 
 
 
 
 
 communication  framework  [Situation,  Background,  Assessment,  Recommendation])  with 
clearly defined mandatory fields, including dietary status, where NBM will be identified as a 
critical safety parameter. 

In  addition,  we  plan  to  embed  a  ‘safety  pause’  within  the  transfer  process,  requiring  both 
transferring  and  receiving  staff  to  confirm  key  patient  risks,  including  NBM  status,  before 
handover  is  completed.  This  will  be  supported  by  clearer  accountability,  including  named 
individuals responsible for providing and receiving handover information.  

This  programme  also  includes  a  review  of  our  standard  operating  procedures  for  patient 
transfers to ensure that appropriate staffing, equipment, and communication processes are 
consistently in place.  

The  Trust  has  strengthened  its  approach  to  incidents  involving  communication/  sharing of 
patient  information,  and  handover  by  undertaking  After  Action  Reviews  (AARs)  in 
accordance with the principles of Patient Safety Incident Response Framework (PSIRF). This 
approach  supports  the  rapid  identification  of  learning,  promotes  a  systems-based 
understanding  of  the  factors  influencing  practice,  and  enables  proportionate  improvement 
actions  to  be  implemented  at  the  point  of  care.  Learning  derived  from  AARs  is  also 
aggregated  and  considered  within  wider  Quality  Improvement  workstreams,  ensuring  that 
themes  relating  to  information  sharing  and  ward-level  handover  arrangements  inform  our 
longer-term organisational improvement and risk reduction strategies This work is being done 
in conjunction with our Patient Safety Faculty.  

To date we have completed 2 after action review events which whilst they relate to differing 
care episodes we recognise there is transferable learning that needs to be combined and 
considered.  

The After Action Review identified that the primary contributory factors related to information 
sharing, communication and system design rather than individual staff actions..  

The review identified weaknesses in the communication of critical safety information during 
ward transfer and handover processes, with no structured mechanism to highlight essential 
swallowing restrictions.  

The review further identified opportunities to strengthen the systems supporting safe care, 
including  the need  for  more effective  integration  of bedside  safety information  into  routine 
workflows,  improved  prompts  to  review  specialist  guidance,  and  greater  visibility  of 
dysphagia-related  risks.  Learning  highlighted  that  reliance  on  documentation  and  posters 
alone may not be sufficient to ensure compliance with specialist feeding plans, particularly 
during periods of ward transfer, high patient turnover or increased operational pressure.  

As  a  result,  immediate  actions  included  reinforcing  Speech  and  Language  Therapy 
recommendations with ward staff, providing additional education regarding dysphagia risks 
and  sharing 
through  ward  safety  huddles  and  wider  service-level 
communications. The identified learning will also inform ongoing Quality Improvement work 
focused on strengthening handover processes, communication of clinical risk information and 
the reliability of safety-critical information transfer across care settings. 

learning 

the 

 
 2. Documentation and Escalation of Information from Families and Carers 

We acknowledge the concern that information provided by Mrs Frehe’s family regarding her 
NBM status was not fully recognised or acted upon. We recognise the vital contribution that 
families and carers make in identifying risks and supporting safe, person-centred care.  

To address this, we are strengthening expectations for staff to clearly document, escalate, 
and act upon concerns raised by families. This will include: 

•  Recording family concerns within the transfer process - utilising family conversations 

into the relevant background section of the handover model.  
•  Reinforcing the requirement for escalation and clinical review 
• 

Introducing  closed-loop  communication  to  confirm  key  risks  such  as  NBM  status 
between clinicians. This would involve nurse to nurse/AHP and or nurse to medic using 
a closed loop handover. This would involve using our existing SBAR handover tool but 
asking or seeking the recipient of the information to confirm the information has been 
heard, understood and acted on. The risk, control measures and escalation plan have 
all  been  verified  in  the  conversation.  At  the  bedside  this  will  involve  nursing  teams 
asking or reviewing what is the risk for this patient, what are we doing about it? And 
what will trigger escalation? If these elements are handed over and confirmed back, 
the team will have achieved a meaningful closed loop communication.  

These  measures  will  be  supported  by  visible  bedside  alerts  and  reinforced  through  daily 
safety huddles  to ensure  a  consistent,  shared  understanding  amongst  all members of  the 
care team.  

3. Clinical Education and Competency 

We  are  continuing  to  strengthen  education  and  training  for  clinical  staff  in  relation  to 
dysphagia, aspiration risk,  and  safe management  of nutrition  and hydration.  This includes 
targeted  ward-based 
teaching  and  promotion  of  the  International  Dysphagia  Diet 
Standardisation Initiative (IDDSI) e-learning programme, delivered in collaboration with our 
speech  and  language  therapy  colleagues.  We  would  aim  to  have  90%  of  staff  within  the 
service group trained within the next 6 months. Our clinical skills facilitators are promoting 
this training alongside delivery of their snack box training in conjunction with our hydration 
and nutrition team.  

This training focuses on improving staff understanding of safe swallowing, appropriate dietary 
modifications, escalation processes, and interim safety measures while awaiting specialist 
assessment.  

Training  compliance  and  impact  will  be  monitored  through  established  governance 
mechanisms, including the PSIRF and review of incident data. Hydration and nutrition remain 
a key local priority within this framework.  

4. Visual Identification and Safety Communication 

We have identified the need to improve the visibility of NBM status across all clinical settings. 
As  part  of  our  improvement  work,  we  are  reviewing  how  patient  safety  information  is 
communicated  both  during  transfers  and  within  ward  environments.  Currently  information 
about a patient such as nil by mouth status will be written behind the bedspace utilising the 

 
 
 
 patient glance board. This is updated using a whiteboard pen. This safety critical information 
should also be considered at the ward daily safety huddle so that all ward team members are 
aware.  

This includes work to: 

•  Standardise bedside information and safety alerts 
• 
•  Develop  a  Trust-wide  handover 

framework 

Improve the consistency of safety huddles, briefings, and handovers 

that  supports  clear,  concise 

communication of key patient safety risks, including NBM status 

This will ensure that critical information is consistently visible, up to date, and understood by 
all members of the multidisciplinary team.  

Governance, Oversight and Assurance 

All actions arising from this work will be captured within a structured and tracked action plan. 
Progress will be monitored through the Trust’s governance framework, including the Patient 
Safety Incident Response Framework and Ward Accreditation Programme.   

This  will  enable  triangulation  of  audit  findings,  incident  trends,  patient  experience,  and 
learning to ensure that improvements are effectively implemented, embedded, and sustained 
across the organisation.   

We fully recognise the seriousness of the concerns raised and are committed to ensuring 
that robust systems are in place to support safe communication and care delivery for patients 
at risk of aspiration. We are confident that the actions outlined above will deliver meaningful 
and measurable improvements to patient safety.   

I hope this response addresses the concerns raised in your Regulation 28 Report.  

Please do not hesitate to contact me if you require any further information.   

Yours sincerely 

Chief Executive