Coroner warns of staff shortage after inpatient death

A coroner has warned that more people could die because of a shortage of dietitians for psychiatric inpatients, after the death of a woman whose nutritional needs went unmet.

Rachel Redman, assistant coroner for East Sussex, issued a Prevention of Future Deaths report to NHS England and the Department of Health and Social Care after the death of 69-year-old Neeshat Dalal in December 2022. It was published this month with both responses.

Ms Dalal was sectioned under section 2 of the Mental Health Act for severe depression and struggling to eat and drink. She was admitted to Sussex Partnership Foundation Trust’s Heathfield Ward at Eastbourne District General Hospital. She collapsed during her third round of electroconvulsive therapy and died the following day of a heart attack.

A jury inquest found staff had given inadequate consideration to whether she was physically unable to eat and drink, rather than refusing food as a means of ending her life. Her nutritional needs “were not appropriately met”, it found, and she needed a dietitian and a more timely gastroenterology referral. The jury also criticised East Sussex Healthcare Trust over vasopressor use and a delay in moving her to high dependency care.

Ms Redman’s single matter of concern was funding for “appropriately qualified dieticians” to meet the nutritional needs of psychiatric inpatients at the trust and “in other trusts where such support does not already exist”.

She said she had heard evidence from the trust’s clinical director that “SPFT’s lack of funding for a dietetic resource extends to trusts nationwide and that this is not a local problem experienced by this trust alone”.

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Source: HSJ, 19 August 2026