The report said Frehe had been given food and drink on 25 August 2025.
It added this led to her vomiting and her condition “deteriorating significantly” until she died in hospital the same day.
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.
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.