Somerset NHS Foundation Trust has expressed its regret after important information about a patient’s nil-by-mouth status was not properly communicated, contributing to the death of a 97-year-old woman at Yeovil District Hospital.
Jacqueline Frehe was admitted on 24 August 2025 with vomiting and a productive cough. She was assessed in the emergency department, where it was noted that she likely aspirated vomit and secretions, which led to pneumonia. Following this assessment, her treatment plan included a nil-by-mouth order to prevent further aspiration risks.
However, a report following an inquest into Mrs Frehe’s death found that her nil-by-mouth status was not adequately communicated between the emergency department and staff on the Acute Medical Unit where she was subsequently cared for. Additionally, her family raised concerns about her feeding status, but this was not documented by hospital staff.
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On the morning of 25 August, Mrs Frehe was given food and drink, which triggered a vomiting episode and is believed to have contributed to her significant deterioration and death approximately two hours later. The cause of death was recorded as natural causes, with aspiration of vomit after eating and drinking noted as a contributing factor.
Somerset’s Area Coroner, Vanessa McKinlay, expressed concern that without action, similar incidents could occur in future. She highlighted that the hospital had not taken sufficient steps to ensure consistent communication of critical patient information.
In response, Professor Deirdre Fowler, Chief Nurse and Midwife at Somerset NHS Foundation Trust, offered the family the trust’s deepest sympathies. She acknowledged that opportunities were missed to ensure vital care information was clearly shared and acted upon, and apologised for these failings.
Professor Fowler outlined that the trust has since taken measures to improve how key patient safety information is shared and documented. These include enhanced handover processes, increased emphasis on listening to families and carers, strengthened training on dysphagia and aspiration risks, and a review of communication methods across wards.
“Patient safety is our highest priority,” said Professor Fowler. “We remain committed to learning from this case and continuously improving the care we provide.”