A coroner has issued a warning to Tameside hospital after it was found a patient’s lack of checks before their death could put future patients at risk
Tameside General Hospital has been issued a warning by a coroner(Image: MEN Media)
A coroner has warned of a risk of future deaths at a Greater Manchester hospital after a patient at high risk of malnutrition was not given vital food checks.
Brian Smith, who was being treated for terminal cancer, was admitted to Tameside General Hospital after falling at his home in November last year. He died later that same month.
An inquest heard that during an earlier admission, the 83-year-old had poor diet and ability to eat. He also had a score of three out of six on the Malnutrition Universal Screening Tool (MUST).
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This score should have triggered daily food and fluid monitoring charts upon his admission to hospital, according to evidence heard by the coroner. However, there was no evidence that the charts were ever used, the coroner said.
It was also heard that Mr Smith was discharged from hospital without being seen by a dietitian.
Assistant Coroner Anna Morris has now issued a Prevention of Future Deaths report to Tameside General Hospital, warning that unless action is taken, there is a “significant risk of future deaths”.
Risk of future deaths, coroner says
Mr Smith had been admitted to Tameside General Hospital between November 4 and 6, 2025, where he was treated for urosepsis – a type of sepsis that occurs when a urinary tract infection (UTI) spreads and enters the bloodstream. He was admitted again on November 24 after falling at home and fracturing his left hip.
His condition deteriorated two days later and a CT scan showed ischaemic colitis. He was treated with antibiotics for suspected sepsis but continued to deteriorate. He died in hospital on November 28, aged 83.
The inquest found his medical cause of death was sepsis due to pseudomembranous colitis, with mesothelioma – a form of cancer – due to asbestosis and his fractured hip also contributing.
The coroner concluded that Mr Smith died from complications which developed from pseudomembranous colitis – inflammation of the large intestine. She said his “overall physiological reserve” had been weakened by his fall and fractured hip, as well as his terminal cancer.
The Prevention of Future Deaths report does not state that the nutrition concerns caused Mr Smith’s death. However, the coroner raised concerns that a patient whose diet was known to be poor should have had his nutrition closely monitored, but did not. She warned that if this continued, there was a risk that future deaths could occur.
What the NHS trust has said
In its response to the coroner, Tameside and Glossop Integrated Care NHS Foundation Trust gave its “sincere condolences” to Mr Smith’s family.
It added: “The Trust remains committed to continuous improvement in patient safety and ensuring that learning from this case is embedded in practice. At Tameside and Glossop Integrated Care NHS Foundation Trust, it is our prerogative to ensure that healthcare services are safe, effective, accountable and continuously improving.
“It is important to us that concerns are reviewed, and learning identified and shared across clinical teams as this helps us to strive to prevent harm and improve outcomes for our patients.”
The Trust said patients with a MUST score of three or more would now be referred to its dietitian service and have daily food and fluid charts completed “immediately”.
It said staff training on nutrition and fluid monitoring was mandatory and that the case of Mr Smith had been developed into a case study which was shared across all wards in July. It has also carried out monthly audits of food and fluid charts.
The Trust’s own figures show that the proportion of required food charts which were fully completed across adult inpatient wards was 89 per cent in April, rising to 95 per cent in May and 97 per cent in June.
Following Mr Smith’s inquest, the Trust said its Dietitian Service was carrying out a separate audit of 50 patients on its Acute Medical Unit over a 48-hour period.
The audit is intended to check whether MUST scores have been calculated correctly, food charts completed and appropriate dietitian referrals made.
The Trust said the findings would be fed back to the Acute Medical Unit and its Nutrition and Hydration Group in autumn 2026.