A healthcare trust says it has changed its guidelines after a 97-year-old woman was given food when she was nil-by-mouth, which led to her death.<\/p>\n
Coroner for Somerset Vanessa McKinlay wrote a prevention of future deaths report<\/a> following the inquest into the death of Jacqueline Frehe, who died at Yeovil District Hospital in Somerset.<\/p>\n The inquest heard that when she was transferred from A&E to another ward, the staff there were not made aware that she was nil-by-mouth.<\/p>\n Somerset NHS Foundation Trust said it extended its “deepest sympathies” and apologised to Frehe’s family and explained it was taking action on the coroner’s findings.<\/p>\n More from Somerset<\/p>\n The report said Frehe had been given food and drink on 25 August 2025.<\/p>\n It added this led to her vomiting and her condition “deteriorating significantly” until she died in hospital the same day.<\/p>\n The coroner said not only was the nil-by-mouth order not communicated between wards, but when Frehe’s family mentioned her nil-by-mouth status, this was not documented by ward staff.<\/p>\n Somerset NHS Foundation Trust has since said it will improve its standardisation of emergency department-to-ward handover, how staff document, escalate, and act upon concerns raised by families, and will strengthen its education and training for clinical staff in relation to dysphagia [difficulty or discomfort when swallowing foods and liquids], aspiration risk, and safe management of nutrition and hydration.<\/p>\n ‘We are sorry’<\/p>\n Prof Deirdre Fowler, chief nurse and midwife at Somerset NHS Foundation Trust, said they had “carefully considered” the coroner’s findings.<\/p>\n “We extend our deepest sympathies to Mrs Frehe’s family at this very difficult time,” she said.<\/p>\n “We recognise that opportunities were missed to ensure important information about her care was consistently communicated and acted upon, and we are sorry for this.<\/p>\n “Patient safety is our highest priority, and we remain committed to learning from this case and continually improving the care we provide.”<\/p>\n Follow BBC Somerset on Facebook<\/a> and X<\/a>. Send your story ideas to us on email or via WhatsApp on 0800 313 4630<\/a>.<\/p>\n More on this storyRelated internet links