 to be completed is dependent on a patient’s Malnutrition Universal Screening Tool (MUST) score. Miss A was screened using MUST on her admission on 2 March 2018. Her weight of 63.5kg (wet weight with ascites) was used for this assessment, which gave her a body mass index (BMI) of 24kg/m2. This resulted in her MUST score being calculated as 0.
27.	As Miss A’s estimated dry weight was around 53kg, this would very likely give her a lower BMI of around 20kg/m2. Had these values been used, a higher MUST score would have been generated. Given her history of poor intake and her clinical condition (decompensated liver disease) she should have been given a MUST score of at least 2 due to the disease affect score.
28.	According to the Trust’s Nutritional Screening Policy for Adult Inpatients, for patients with a MUST score of 1 or 2, the Trust should keep food record charts documenting all diet taken. There are gaps in the food intake charts with there being no record of food intake at all on 6 March 2018, 7 March 2018 and 13 March 2018.
29.	We recognise that the records mention Miss A spending time off the ward frequently. However, if this was the reason for the gaps in the food intake chart, a note should have been made in the food intake chart at the time to say an attempt had been made to complete it. Our view is that the error in calculating Miss A’s MUST score and the gaps in the completion of the food intake charts are failings by the Trust. We will go on to consider the impact of these failings later in this document.
30.	Mrs A says that after the dietician recommended a high protein diet with nutritional supplements for Miss A, there were many occasions where the Trust did not provide this. The Trust says that Miss A’s nutritional supplements were always given as prescribed except on three occasions where Miss A declined them. The Trust says that Miss A was often off the ward at mealtimes, which made it difficult for staff to monitor her nutritional intake. It says that the food recorded on the food intake chart mostly fits the special dietary requirement suggested by the dietician but some of the choices made are down to patient preference.
31.	We asked the Trust to give us information about its process for the provision of therapeutic diets, including a high protein diet. It said that once a patient is reviewed and assessed by a dietician, the patient is educated on how to request the recommended therapeutic diet from this menu.
32.	The Trust said the ward has a nutritional board that highlight patients’ specialist dietary needs. The high protein diet is requested via a completed menu card for each patient. These menu cards are distributed by the ward staff to the ward patients after review of the board, with each patient then choosing their preferred menu options from the recommended diet. If a patient lacks capacity, the nursing staff will assist the patient in choosing the recommended meals on the menu. The completed menu card is then returned by the ward staff to the Catering Team the day before the meal is provided. During mealtimes, the ward’s mealtime coordinator also uses the ward’s nutritional board as guidance to ensure that patients each receive their recommended meal.
33.	In reaching our views in relation to this part of the complaint we have considered advice received from our dietician adviser as well as the guidance referred to. We are satisfied from the notes made by the dietician when she assessed Miss A on 2 March 2018 that she was provided with the necessary information on how to make informed meal choices. We will not be able to give any view as to whether the nutritional board contained the correct dietary requirements for Miss A as although it is documented in the dietician’s notes in Miss A’s medical records, the dietary requirement is not recorded in the nursing records between 2 and 7 March 2018.
34.	The Trust says that despite the error in the nursing documentation, the food recorded on the food intake chart mostly fits with a high protein diet. We have considered this carefully and do not agree that the food intake chart shows that Miss A’s recommended diet was mostly adhered to. There are no entries at all on 2 March 2018 or 6 March 2018 and the entries for the evening meal on 4 March 2018 and 5 March 2018 both say sandwiches, so there is no record of whether these were from the high protein options or not.
35.	We have considered Mrs A’s views that her daughter did not receive high protein menu options and the records of the dietician’s concerns in this regard. These matters concerned the dietician enough that she wished to raise an incident report about it. We have also considered that there is nothing in the documentation kept by the Trust to suggest that Miss A did receive high protein menu options and that there nothing in the evidence to show us on the balance of probabilities that the requirement for those options were recorded on the ward’s nutrition board. On balance, we have concluded that there were failings in the Trust’s provision of the recommended high protein diet. We will return to these matters to consider the likely impact.
36.	Mrs A says that when the dietician assessed Miss A on 9 March 2018, she said she was going to raise an incident report as Miss A had not been getting the right meals and this had compromised her care. The Trust says that the dietician could not access its incident reporting system at the time due to IT issues but that she instead discussed the issue with ward staff.
37.	We note that the dietician did attempt to raise an incident report but was unable to do so at the time. She therefore alerted the ward staff of the issue instead. We consider that this was a reasonable action to take in the circumstances. We consider that it would have been helpful if the dietician had communicated this to Mrs A at the time. However, our view is that we do not consider that the fact she did not do so to be significant enough to constitute a failing in service.
38.	On 14 March 2018 a doctor noted in Miss A’s medical records that she had eaten and drunk, when her food chart shows she had only had yoghurt. Mrs A feels this paints an inaccurate picture of Miss A’s nutritional status. However, the Trust says the comment was intended as meaning Miss A’s had managed some oral intake.
39.	In reaching our views in relation to this part of the complaint we have considered advice received from our dietician adviser as well as the guidance referred to. We understand that the comment recorded by the doctor was likely intended to say that Miss A was taking diet and fluids. The doctor made no mention of the adequacy of her intake, so we do not agree this statement is misleading or inappropriate.  Our view is that there is no failing here.
40.	We have identified failings in the lack of consideration of inserting a feeding tube on 14 March 2018, the error in the calculation of Miss A’s MUST score, the gaps in the completion of the food charts and the issues in the provision of a high protein diet.
41.	We have very carefully considered the failings we identified and whether the evidence available indicates Miss A’s death might have been prevented if it were not for these occurring. In doing so we have considered advice received from our gastroenterology adviser. We can see that the main period when Miss A’s nutrition was substantially below the recommended levels was 14 March to 16 March 2018. We understand that given the severity of Miss A’s underlying liver disease and the flu she was suffering from, it is very unlikely that the failings identified would have had any significant impact on her chances of survival or that Miss A’s death could have been prevented.
42.	We do not know what the outcome would have been if consideration had been given to insertion of a feeding tube on 14 March 2018, or whether the Trust’s recording of Miss A’s nutritional intake would have improved had her MUST score been correctly calculated. We cannot know how many times food intake information was available but not inputted or on how many occasions staff should simply have recorded that completion had not been possible due to absence from the ward. The gaps in the food intake chart also mean that we cannot say on balance what impact the issues with the provision of the high protein diet had on Miss A’s nutritional status, although we have not seen any evidence of a significant clinical impact, as above.
43.	The impact on Mrs A of the failings we have identified is the uncertainty she will undoubtedly be left with over the impact these issues may have had on Miss A’s nutritional status during her admission. This will no doubt leave Mrs A questioning whether her daughter’s chances of survival could have improved if these failings had not occurred. As we have identified several failings which have caused Mrs A avoidable uncertainty and distress, we uphold this part of the complaint. We have made a recommendation below to put things right.
44.	Mrs A feels that the Trust did not sufficiently take note of and treat Miss A’s oedema and water retention. She also believes the Trust should have inserted an abdominal drain for Miss A after it was suggested by night staff. Mrs A feels that Miss A should have been transferred to Critical Care sooner and that dialysis should havenation.
45.	In reaching our views in relation to this part of the complaint we have considered advice received from our gastroenterologist adviser as well as the guidance referred to. We understand that it is common for patients with liver disease to have too much water and salt in the body. This tends to accumulate in the legs (oedema) and the abdomen (ascites). The function of diuretics is to remove water and salt from the body slowly by increasing the amount lost from the body in