Hospital sorry after patient's nil-by-mouth death

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.

Coroner for Somerset Vanessa McKinlay wrote a prevention of future deaths report following the inquest into the death of Jacqueline Frehe, who died at Yeovil District Hospital in Somerset.

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.

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.

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.

Prof Deirdre Fowler, chief nurse and midwife at Somerset NHS Foundation Trust, said they had "carefully considered" the coroner's findings.

"We extend our deepest sympathies to Mrs Frehe's family at this very difficult time," she said.

"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.

"Patient safety is our highest priority, and we remain committed to learning from this case and continually improving the care we provide."

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