Care Home Malnutrition Negligence: When Does Nutritional Care Fall Below Standard?

Malnutrition in care home settings is not a marginal problem. Studies consistently show that a significant proportion of care home residents are malnourished or at nutritional risk on admission, and that this risk frequently increases rather than decreases under residential care. When a resident deteriorates, is admitted to hospital in a state of severe malnutrition, or dies with malnutrition in the clinical picture, the question of whether the care home met an acceptable nutritional standard is a legitimate and important one.

As a dietitian expert witness, I am instructed in care home malnutrition cases to assess the nutritional care provided, the standard against which it should be measured, and whether failures in that care caused or contributed to the harm alleged.

The Standard of Care in Care Home Settings

The nutritional standard applicable in care home settings is not identical to the hospital standard, but it is not without structure. NICE CG32 on nutrition support in adults applies to care homes as well as hospitals. It requires that all adults in care settings be screened for nutritional risk using a validated screening tool such as MUST, that the results be used to implement appropriate care plans, and that residents receiving nutritional support are monitored and reviewed.

The Care Quality Commission's fundamental standards require that care and treatment meets residents' needs, including nutritional needs. Under Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, providers must ensure that people have adequate nutrition and hydration to sustain life and good health. These are enforceable standards, not aspirational ones, and they frame the expert analysis in civil negligence and regulatory proceedings alike.

What Inadequate Nutritional Care Looks Like

The failure patterns I encounter most frequently in care home malnutrition cases follow a consistent structure.

MUST screening on admission is completed and indicates medium or high nutritional risk. The care plan does not reflect this. No dietetic referral is made. Food and fluid intake monitoring, where it occurs at all, is inconsistent and not acted upon. The resident's weight is not recorded at the required intervals. When the resident deteriorates and is admitted to hospital, they are found to have a BMI consistent with moderate to severe malnutrition and biochemical markers reflecting prolonged inadequate nutrition.

The clinical record in care homes is often sparser than in acute hospital settings. The absence of a food record chart, the absence of recorded weight measurements, and the absence of any documentation of a nutritional care plan are all findings in their own right. Where those records are inadequate, that inadequacy forms part of the expert analysis.

The MUST Score and What It Should Trigger

MUST produces a score based on BMI, unintentional weight loss, and the effect of acute illness on dietary intake. A score of one indicates medium risk and requires observation with repeat screening at regular intervals. A score of two or above indicates high risk and requires dietetic referral, increased monitoring frequency, and an active nutritional care plan.

A documented MUST score of two or above that is followed by no meaningful action represents a clear failure against the standard NICE CG32 requires. The expert can identify that failure, locate it in the record, and assess its likely clinical consequences.

Causation: Was the Malnutrition Caused or Exacerbated by the Care Home's Failures?

The causation question requires the expert to distinguish between malnutrition that was present on admission and malnutrition that developed or worsened under the care home's management. This requires review of admission weight and nutritional status where records exist, GP records predating admission, any prior hospital records, and the trajectory of weight change during the period of care home residence.

Where a resident was admitted with moderate nutritional risk and discharged to hospital two years later with severe malnutrition, the expert analysis should address whether that deterioration was a consequence of the care home's failure to implement appropriate nutritional support, or whether it was an inevitable consequence of the resident's underlying conditions. These possibilities are often not mutually exclusive, and the expert should address both.

Practical Points for Instructing Solicitors

Records to obtain include: MUST screening documentation from admission and throughout the period of residence; weight records with dates; food and fluid intake monitoring records; care plans referencing nutrition and hydration; correspondence with the GP, dietitian, or other healthcare professionals; and hospital admission and discharge records for any admissions during the period of care.

Key instruction questions: Was nutritional risk identified and acted upon appropriately from admission? Were nutritional care planning and monitoring consistent with NICE CG32 and CQC regulations? Were concerns referred to a dietitian or GP in a timely manner? What contribution, if any, did failures in nutritional care make to the resident's deterioration or death?