– Neeshat Dalal

I am Rachel REDMAN, Assistant Coroner, for East Sussex.

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online . The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary.

SUMMARY OF CORONER’S CONCERN At an inquest touching the death of Neeshat Dalal who died on 14.12.2022 aged 69, which I heard with a jury, evidence was given that Sussex Partnership NHS Foundation Trust (SPFT) did not have funding for a dietician even though mentally ill patients with nutritional needs required support from a suitably qualified healthcare professional. The failure to properly assess Neeshat’s inability to eat and reasons why she was not eating whilst an in patient on Heathfield Ward, Eastbourne District General Hospital from 30.11.2022 to 13.11.2022, and her subsequent admission to the hospital’s Emergency Department on 13.12.2022 may have contributed to her death on 14.12.2022 of an acute myocardial infarction due to a blocked coronary artery and ischaemic heart disease. On further questioning of the Trust’s Clinical Director, I heard evidence 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. My concern is that severely mentally unwell patients such as Neeshat who was sectioned under s2 Mental Health Act 1983 are not receiving dietary and nutritional support from a qualified dietician when experiencing difficulties in eating and drinking.