Suzanne Pemberton
5 Jan 2026 · Coroner Sean Horstead · Essex
The coroner's concerns
1. lack of dietetic service out of hours
“At present there is no funding in place to provide any dietetic service for weekends or bank holidays. Wards are encouraged and trained to implement the Malnutrition Universal Screening Time 'MUST' care plans and utilise enteral feeding starter regimes where appropriate whilst awaiting dietetic input.”
2. absence of specialist dietetic cover outside normal hours
“no specialist dietetic service or cover of any kind at all for patients at CGH”
3. inadequate implementation and monitoring of nutrition plans
“cases where, as examples, Naso-gastric feeding may not be started as soon as it should be, or that there will occasions when the written generic 're-feeding' guides provided by her Team to the wards may not be appropriately followed (with such failures not being picked up and corrected by her Team”