Somerset NHS Foundation Trust has issued an apology after a 97-year-old patient died shortly after being given food and drink in hospital, despite having a nil-by-mouth order in place.
Jacqueline Frehe died on 25 August 2025, approximately two hours after receiving food and drink on a ward at Yeovil District Hospital. She had been admitted to the emergency department the previous day with vomiting and a productive cough. It is believed she aspirated vomit and secretions, leading to pneumonia, according to a prevention of future deaths report following an inquest which concluded on 21 May 2026.
Mrs Frehe’s treatment plan specified she should remain nil-by-mouth. However, the report found that this critical information was not properly communicated between the emergency department and staff on the Acute Medical Unit ward. Additionally, her nil-by-mouth status was not adequately documented, despite her family raising concerns about it.
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On the morning of 25 August, Mrs Frehe was given food and drink, which precipitated a vomiting episode. The report states this likely contributed to her rapid decline and subsequent death.
The cause of death was recorded as natural causes, with aspiration after eating and drinking contributing to her passing.
Area Coroner Vanessa McKinlay highlighted a risk of similar incidents happening in future unless corrective action is taken. She expressed dissatisfaction with the measures currently in place to ensure such crucial information is shared and acted upon appropriately.
In response, Professor Deirdre Fowler, chief nurse and midwife at Somerset NHS Foundation Trust, expressed deep sympathies to Mrs Frehe’s family and acknowledged that “opportunities were missed” in communicating her care needs.
Professor Fowler stated: “We have carefully considered the coroner’s findings and have already made improvements to how critical patient information is shared, documented and escalated. This includes enhancing handover processes, emphasising the importance of listening to families and carers, reinforcing training on swallowing difficulties and aspiration risks, and reviewing communication methods across our wards. Patient safety remains our highest priority, and we are committed to learning from this case to continually improve our care.”